Exercise and Falls PreventionPreliminary Results from a Community-Based

Exercise Intervention

April 3, 2009

Christian Thompson, Ph.D.Department of Exercise & Sport Science

University of San Francisco

The Older Adult Continuum

This Can Happen to Both of Them!

Too Bad It’s Not Funny… Over 1/3 of people aged of 65+ fall each year

In 2004, over 1.8 million seniors were treated for fall-related injuries at emergency rooms

Approx. 400,000 fractures per year due to falls

Over 20% of hip fractures result in death in 1 yr

Problem will only continue to increase with changing demographics

Sources: CDC, 2007; Kannus et al., 2005; Ngyuen et al., 2007

Relevant Health Data for California and San Francisco County

Over 25% of people living in San Francisco are over the age of 65

Almost 12% of older Californians fell more than once in 2003

Diagnosed diabetes increased from 15% in 2001 to 17.5% in 2005

Diagnosed hypertension increased from 53% in 2001 to 60% in 2003

Source: UCLA Center for Health Policy Research, 2008

Factors Affecting Falls

Extrinsic FactorsExternal Issues

– Weather or outdoor conditions

– House clutter and obstacles

– Poor lighting– Lack of adaptive

devices in the home– Inappropriate

footwear/clothing

Intrinsic FactorsInternal Issues

– History of Falling– Chronic Diseases &

Medical Conditions– Sensory/Vestibular

Impairments– Medication Effects– Functional Level

(Strength, Posture, Gait)

Sources: (Rose, 2003; Tinetti et al., 1988; Carter, 2001; Lehtola et al., 2006)

Risk with number of risk factors present

Regularly ImplementedIntervention Strategies

MultifactorialAddress both I&E risks

– Environmental hazards

– Medication modification

– Sensory deficits– Disease

management– Exercise– Education

Exercise-OnlyAddress modifiable functional limitations

– Lower body strength– Static/Dynamic balance– Flexibility– Gait modification– Cardiovascular

Group vs. IndividualSupervised vs. Unsupervised

Sources: Lord et al., 1995; Province et al., 1995; Tinetti et al., 1994

Randomized Controlled Trials Multifactorial Interventions – 6 Studies

Intervention Characteristics

Exercise (6)

Home Hazard Reduction (3)Day et al., 2002, Sjosten et al., 2007; Steinberg et al., 2000)

Medical/Medication Intervention (5)Day et al., 2002; Steinberg et al., 2000; Shumway-Cook et al., 2007; Campbell et al., 1999; Sjosten et al., 2007

Vision (2) Day et al., 2002; Shumway-Cook et al., 2007

Education (2) Shumway-Cook et al., 2007; Sjosten et al., 2007

Nutrition (1) Swanenburg et al., 2007

Randomized Controlled Trials Multifactorial Interventions

Relevant FindingsFalls Reduction Significant reduction in falls in 3 of 6 studies

– Day et al., 2002; Steinberg et al., 2000; Swanenburg et al., 2007

Fall Risk Reduction Improvement in some/all fall risk factors in 5 of 6 studies

– Measured by Balance assessment inventories, Strength, Gait Analysis, Agility/Dynamic Balance Assessments, Balance Confidence/Fear of Falling scales

– Only Sjosten, et al., 2007 did not report improvement

Limitations Variability in participant selection, exercise dose, exercise

program content, program duration Questionable statistical analyses

Randomized Controlled TrialsExercise-Only Interventions – 9 Studies

Included Exercise Program CharacteristicsResistance Training (7) – Barnett et al., 2003; Freiberger et al.,

2007; Woo et al., 2007; Suzuki et al., 2004; Luukinen et al., 2007; Rubenstein et al., 2000; Lin et al., 2006

Static Balance Training (5) – Barnett et al., 2003; Freiberger et al., 2007; Madureira et al., 2007; Suzuki et al., 2004; Rubenstein et al., 2000

Agility/Dynamic Balance Training (8)Gait Enhancement Training (4) – Barnett et al., 2003; Madureira

et al., 2007; Suzuki et al., 2004; Rubenstein et al., 2000Aerobic/Cardiovascular Training (4) – Barnett et al., 2003;

Freiberger et al., 2007; Luukinen et al., 2007; Rubenstein et al., 2000 Flexibility Training (6) – All except Madureira 2007 & Suzuki 2004

Tai Chi (4) – Barnett et al., 2003; Woo et al., 2007; Li et al., 2005, Lin et al., 2006

Supervised Group Exercise (4), Home-based Exercise (1), Combination (4)

Randomized Controlled Trials Exercise-Only Interventions

Relevant FindingsFalls Reduction Significant reduction in falls in 6 of 9 studies

– Barnett et al., 2003; Freiberger et al., 2007; Li et al., 2005; Madureira et al., 2007; Suzuki et al., 2004; Rubenstein et al., 2000

Fall Risk Reduction Improvement in some/all fall risk factors in 5 of 6

studies – Measured by Balance assessment inventories, Strength, Gait

Analysis, Agility/Dynamic Balance Assessments, Balance Confidence/Fear of Falling scales

– Only Woo, et al., 2007 did not report improvement

Limitations Variability in participant selection, exercise dose,

exercise program content, program duration Questionable statistical analyses

Conclusions Concerning Exercise for Falls Prevention

Exercise has been shown to exert a strong effect on functional level and modifiable intrinsic falls risk factors

Exercise has been shown in several studies to reduce future falls

Dose-response studies are needed to determine optimal training recommendations

Purpose & Hypotheses

Determine the effect of a 12-week progressive functional training program

on falls risk, balance confidence, perceptions of health and falls

occurrence in community-dwelling older adults who have sustained at least one

accidental fall in the past 6 months

Intervention Description

12-week Progressive ProgramThree 4-week phases

Dynamic warm-up Sensory integration exercises Strength training Balance training Gait enhancement training Dynamic cool-down

60 Minutes, 2 days per weekLed by certified fitness professionals

Exercise Week 4 Week 8 Week 12

Hip Rotations Seated30 sec each

Seated30 sec each

Standing30 sec each

Stand w/ Rotating Head (eyes fixed) – 30 sec No March March 15 sec March 30 sec

Chair Squats w/ Forward Reach 2x15 3x15 3x25

Dumbbell Underhand Front Raise (Chest) Seated 2x15

Standing 3x15

Standing 1 Arm 3x15 each

Dumbbell Cobra (Back) Seated 2x15

Standing 3x15

Standing 1 Arm 3x15 each

Side Steps (Wide Steps to Feet Together) 2 stepsForward Reach

60 sec

3 stepsSame Reach

90 sec

4 stepsOpposite Reach

120 sec

Mobility Ladder Pattern Forward Stepping

2x through

Alt. Wide &Narrow Steps

2x through

Diagonal Steps to1 Leg Balance

2x through

Partner Squat & Ball Pass Face-to-Face1x20 each

Side-by-Side2x20 each

Side-by-SideLow to High2x20 each

Exercise Progression Examples

Outcome Measures

Physiological Assessments– Functional Reach Test (Limits of Stability)– 30 sec Chair Stand (Lower Body Strength)– Timed Up-And-Go (Agility & Dyn. Balance)

Questionnaires– Activity Specific Balance Confidence Scale– SF-12 Quality of Life Questionnaire

Falls Occurrence– Monthly Phone Interviews for 1 year

Study Sample Community-dwelling older adults ≥ 65 yrs Sustained accidental fall in last 6 mos

– FICSIT falls definition Must be able to ambulate 30 feet w/o AD Free of significant sensory/vestibular

dysfunction, PD, uncontrolled metabolic disease, uncontrolled cardiovascular disease

Available for study duration

Total Phone Contacts82

Attended Screening61

Did Not Qualify10

Qualified and Did Not Enroll6

Qualified and Enrolled45

Did Not Qualify/Not Interested21

Completed < 20 Visits7

Dropped Out3

Recruitment & Intervention

Completed 20+ Visits35

Controls40

Physiological MeasuresANCOVA – Baseline as Covariate

-10

0

10

20

30

40

50

60

FR CS TUG

Exercise

Control

% C

han

ge

p = .0001

p = .008

p = .04

AcknowledgementsFunding:

San Francisco Dept. Aging & Adult ServicesCalifornia Wellness FoundationUniversity of San Francisco Faculty Development Fund

Community Partners:30th Street Senior Center, San Francisco Senior Centers,Inc., Kaiser San Francisco, San Francisco Examiner,Fromm Institute for Lifelong Learning at USF

Research Associates/Assistants:Dr. Diana Lattimore, Irina Fedulow, Brigitte Dubon, Sarah

Simunovich, Jermelle Newman, Taylor Harrington, Sarah Wallenrod, Patricia Bufalini, Matt Lieb, Ben Dessard

Dr. Christian Thompson

Department of Exercise & Sport Science

University of San Francisco

2130 Fulton Street

San Francisco, CA 94117

cjthompson@usfca.edu

(415) 422-5270