personal choice report - stay on your feet®
TRANSCRIPT
Personal Choice Report Benefits of recreation activities for falls
prevention
Prepared by: Injury Control Council of Western Australia
Date: September 2015
Personal Choice Report
September 2015
Page 1
Suggested citation: Injury Control Council of Western Australia (2015). Stay On Your Feet® Personal Choice Report - Benefits of recreation activities for falls prevention. West Perth: Injury Control Council of Western Australia.
Important disclaimer: All information and content in this Material is provided in good faith of the Injury Control Council of
Western Australia (ICCWA), and is based on sources believed to be reliable and accurate at the
time of development. The Injury Control of Western Australia and their respective officers,
employees and agents, do not accept legal liability or responsibility for the Material, or any
consequences arising from its use.
When considering participating in a recreational activity it is important to factor in any potential
risks of participating in the activity. This document outlines potential risks of each recreational
activity on balance, however it does not consider other risks that may exist beyond balance. If you
have any queries or concerns about your potential risks of participating in a recreational activity it
is recommended that you speak to your doctor prior to participating.
Contact information: For further information contact Stay On Your Feet® on 1300 30 35 40 or
Personal Choice Report
September 2015
Page 2
Table of Contents
Acknowledgements ...................................................................................................................... 4
Foreword ....................................................................................................................................... 5
Executive Summary ...................................................................................................................... 6
Introduction ................................................................................................................................... 7
Epidemiology of falls .................................................................................................................. 7
Consequences of falls ............................................................................................................... 7
The future impacts of falls.......................................................................................................... 7
Causes of falls ........................................................................................................................... 8
Balance ..................................................................................................................................... 8
Injury Control Council of Western Australia ............................................................................... 8
Stay On Your Feet® ................................................................................................................... 8
Falls Prevention Programs ........................................................................................................... 9
Current falls prevention programs .............................................................................................. 9
Ideal Characteristics of a falls prevention exercise program ...................................................... 9
Recreational Activities ................................................................................................................ 11
Benefits of recreational activities ............................................................................................. 11
Older adults’ participation in recreational activities................................................................... 11
Methodology ............................................................................................................................... 12
Data Sources and Searches .................................................................................................... 12
Study Selection ....................................................................................................................... 12
Review Process ....................................................................................................................... 12
Literature Review ........................................................................................................................ 13
Trails included in the literature review ...................................................................................... 13
Aquarobics .............................................................................................................................. 13
Benefits of Aquarobics for balance .................................................................................. 13
Risks of Aquarobics for balance ...................................................................................... 13
Cycling .................................................................................................................................... 14
Benefits of cycling for balance ......................................................................................... 14
Risks of cycling for balance ............................................................................................. 14
Dancing ................................................................................................................................... 14
Benefits of dancing for balance ....................................................................................... 14
Risks of dancing for balance ........................................................................................... 15
Exergaming ............................................................................................................................. 15
Benefits of Exergaming on balance ................................................................................. 15
Risks of exergaming on balance ..................................................................................... 16
Golf ........................................................................................................................................ 16
Personal Choice Report
September 2015
Page 3
Benefits of golf on balance .............................................................................................. 16
Risks of golf on balance .................................................................................................. 16
Lawn bowls ............................................................................................................................. 16
Benefits of lawn bowls on balance .................................................................................. 17
Risks of lawn bowls on balance ...................................................................................... 17
Lifeball ..................................................................................................................................... 17
Benefits of Lifeball on balance ........................................................................................ 17
Risks of Lifeball on balance............................................................................................. 17
Tai Chi ..................................................................................................................................... 18
Benefits of tai chi on balance .......................................................................................... 18
Risks of Tai Chi on balance............................................................................................. 19
Tennis ..................................................................................................................................... 19
Benefits of tennis on balance .......................................................................................... 19
Risks of tennis on balance .............................................................................................. 19
Walking ................................................................................................................................... 20
Benefits of walking on balance ........................................................................................ 20
Risks of walking on balance ............................................................................................ 20
Yoga ........................................................................................................................................ 21
Benefits of yoga on balance ............................................................................................ 21
Risks of yoga on balance ................................................................................................ 21
Recommendations ...................................................................................................................... 22
Limitations ................................................................................................................................... 23
Next Steps ................................................................................................................................... 24
Glossary ...................................................................................................................................... 25
References .................................................................................................................................. 27
Appendices ................................................................................................................................. 33
Appendix 1: Summary table of included trials (n=30) showing sample size, balance tests used, results, strengths, limitations and conclusions ......................................................................... 33
Personal Choice Report
September 2015
Page 4
Acknowledgements
Stay On Your Feet® would like to acknowledge the individuals, groups and organisations who
contributed their time and experience to producing the final document.
Name Position and organisation
Rachel Meade Evidence and Practice Coordinator, Falls Prevention Programs, ICCWA
Roisin Sweeney Project Assistant, Falls Prevention Programs, ICCWA
Siva Nagendra Volunteer, Falls Prevention Programs, ICCWA
Ailsa Dinnes Manager, Falls Prevention Programs, ICCWA
Emily Anderson Senior Coordinator, Falls Prevention Programs, ICCWA
Michael Atkinson Operations Manager, ICCWA
Dr Nicholas Waldron Clinical Lead, WA Health Falls Prevention Network
Falls Prevention Health Network Executive Advisory Group members
Personal Choice Report
September 2015
Page 5
Foreword
In Western Australia between 2008 and 2012 there were 73,509 hospitalisations due to falls (Department of Health Western Australia, 2015). With the risk of falling increasing with age and Australia’s ageing population, without intervention it is predicted that this number will grow. The impact that falls can have is vast as having a fall can bring about fear of falling, loss of confidence, emotional strain, reduced quality of life, social isolation and an increased risk of early death. There are also direct economic costs accompanying healthcare and indirect costs associated with the productivity lost from the individual or family care giver being unable to work. Due to the prevalence of falls within WA, an ageing population and the range of factors that can impact on an individual’s risk of experiencing a fall, falls prevention requires attention across the lifespan and a multidisciplinary approach. The Falls Prevention Model of Care 2014 (MoC), provides recommendations to achieve best practice across WA and includes the broad uptake of evidence-based exercise programs. However, the current evidence only examines limited programs and these may not suit all older adults. To be inclusive, the MoC supports increased uptake of physical activities that improve balance and are enjoyed by older people themselves. This report by Stay On Your Feet® provides a review of what is known about recreational activity, the benefits and includes the impact on balance and other falls risk factors. The Personal Choice Report outlines the benefits of existing popular, culturally and age appropriate recreational activities in increasing balance and preventing falls. I am confident that by increasing the awareness of the role that balance plays in falls prevention and encouraging older adults to participate in recreational activities; we can reduce the impact that falls are having on Western Australians.
Dr Nicholas Waldron
Clinical Lead, WA Health Falls Prevention Network
September 2015
Personal Choice Report
September 2015
Page 6
Executive Summary
There is strong evidence that participation in exercise programs that are based on balance
exercises, performed for 2-hours per week in an ongoing fashion is effective in preventing falls;
however there is a lack of research into the effect of different recreational activities in relation to
preventing falls in older adults.
The aim of this report is to compile and disseminate information on the benefit(s) of existing
popular, culturally and age appropriate recreational activities in increasing balance which may lead
to preventing falls. This report outlines the identified benefits and risks associated with aqua
aerobics, cycling, dancing, exergaming, golf, lawn bowls, Lifeball, tai chi, tennis, walking and yoga.
Of the recreational activities examined all were found to have positive effects on varying measures
of balance which supports that these activities may have a positive effect of reducing falls risk. Tai
chi was the only activity with direct evidence for preventing falls in high quality trials. The quality
and quantity of research for other activities was limited and comparison between different activities
was not possible, instead the current knowledge risks and additional benefits are described.
Although the finding are encouraging, broad recommendations for specific recreational activities
can’t be made, instead this information can be used to support appropriate and tailored physical
activity that is consistent with the individuals preferences for inclusion in a regular exercise regime.
Further research is required to explore the potential benefits and risks of different recreational
activities, helping to support the general population to adopt exercise behaviours that support good
health and wellbeing.
Personal Choice Report
September 2015
Page 7
Introduction
The Stay On Your Feet® program promotes that popular recreational activities for older adults,
such as lawn bowls and tai chi can be endorsed as an effective way to minimise the age-related
decline in balance and thus reduce the risk of falls.
This report collates findings from academic networks on the benefits of different activities for
preventing falls and maintaining good health, providing evidence that recreational activities can
improve balance and contribute to a reduced risk of falls in older people. The Personal Choice
Report will be available for access on the Stay On Your Feet® website to inform the community,
academic stakeholders and health professionals of initiatives including research, resource
allocation and promotions that reduce the risk of falls. By confirming with evidence which
recreational activities have the potential to contribute to preventing falls it provides the opportunity
for health professionals and community workers to refer their clients to recreational activities with
confidence.
Although the recreational activities outlined in this document can contribute to reducing an
individual’s risk of experiencing a fall, it is also important to factor in any potential risks associated
with the recreational activity. To assist the reader in recognising the potential risks to balance that
can result from participating in the activity; any risks identified in the sited research are included in
the activity summaries. In addition to this as every individual has their own unique characteristics it
is important to not only weigh up the benefits and risks listed in this document but also any risks
that may result due to the participant’s health status.
Epidemiology of falls
As people age, their risk of falling increases with global statistics showing 1 in 4 people over the
age of 60 and 1 in 3 over the age of 65 fall each year (World Health Organisation, 2007). Between
2008 and 2012 there were 73,509 hospitalisations due to falls in Western Australia (Department of
Health, 2015). In 2012 alone hospitalisations in Western Australia due to falls cost approximately
$117,957,168 (Department of Health, 2015).
In Western Australia between 2007 and 2011, there were 756 recorded deaths due to falls
(Department of Health, 2015). Of these, 45% (340) were males and 55% (416) were females.
Consequences of falls
Whilst the risk of falling increases with age, the outcomes of these falls also take on greater
significance. Although most falls produce no major injury, 5 - 15% of community dwelling older
adults who fall each year sustain a serious physical injury such as a hip fracture, head injury,
laceration or are psychologically affected (American Geriatrics Society and British Geriatrics
Society, 2011). Post-fall anxiety syndrome or fear of falling is a recognised consequence of falls. It
can result in self-imposed activity restrictions and loss of confidence in safe ambulation which
leads to further functional decline, depression, social isolation and placing an individual at higher
risk for another fall (Cumming, Salkeld, Thomas, & Szonyi, 2000; Tinetti, Mendes de Leon,
Doucette, & Baker, 1994).
The future impacts of falls
Australia’s population is ageing and it is predicted that 20% of Australians will be 65 years or older
by 2031 (Australian Institute of Health and Welfare, 2012). This means that, the total estimated
health cost attributable to falls-related injury could increase threefold to $1375 million by 2051
(Moller, 2003).
Personal Choice Report
September 2015
Page 8
Causes of falls
A review of 12 retrospective studies, involving 3,628 falls, cited the following most common causes for falls (Rubenstein & Josephson, 2002):
1. Accident/Environmental hazard, fall from bed – 31% 2. Balance impairments and gait disorders, weakness – 17% 3. Other Specified (i.e. arthritis, acute illness, medications or alcohol; pain) – 15% 4. Dizziness/Vertigo – 13% 5. Central nervous system disorder, syncope, drop attacks, epilepsy – 10% 6. Unknown – 5% 7. Confusion and cognitive impairment– 5% 8. Postural hypotension – 3% 9. Visual problems – 2%
Balance
Balance is the second most common cause of falls and can be defined as the ability to maintain
projection of a body’s centre of mass within manageable limits of the base of support or in transit to
a new base of support, as in walking (National Ageing Research Institute, 2006). Without
intervention trends indicate a considerable age-related decline in balance. Individuals aged around
70 years have close to normal balance scores, however there is a significant decline in balance
and greater variability past this age (Downs, Marquez, & Chiarelli, 2014). Fortunately, this decline
in balance is a modifiable risk factor for falls as by maintaining optimum balance longer into life it
reduces the risk of experiencing a fall.
Injury Control Council of Western Australia
ICCWA’s purpose is to advocate, collaborate and deliver programs to minimise harm from injury in
the community using evidence based practice.
Stay On Your Feet®
Stay On Your Feet® is WA’s falls prevention program for older adults living in the community. It
educates community members, health professionals and community workers about how to prevent
slips, trips and falls. Stay On Your Feet® is coordinated by the Injury Control Council of Western
Australia with the support of the Department of Health.
Stay On Your Feet® promotes how to keep active and alert through Move Improve Remove and
evidence informed programs for older adults. Move your body, improve your health, remove
hazards are three steps to keep active and alert to prevent slips, trips and falls.
Within each step there are a number of suggested actions which are based on contemporary falls
prevention evidence. Move Your Body consists of; Build Your Balance and Strengthen Your Legs.
The Personal Choice Report focuses specifically on Build Your Balance which addresses the
second most common cause of falls, impaired balance.
Personal Choice Report
September 2015
Page 9
Falls Prevention Programs
Current falls prevention programs
Due to the impact falls have on the community, there has been extensive randomised trial-based
research into exercise programs that can be used to safely prevent falls in older adults. The Otago
Exercise Program is one such program, with results indicating that the program resulted in a
reduction in falls and a reduction in the rate of injuries for both men and women, particularly for
participants aged 80 years and over who had fallen in the previous year (Sherrington et al. 2008).
The Stay Safe, Stay Active study is another example of an exercise intervention aimed at reducing
falls. Stay Safe, Stay Active utilised weekly structured group sessions of moderate intensity
exercise in both community and home settings, with results specifying that community dwelling
older adults who participated in this study over the one year period were 40% less likely to fall and
one-third of participants were less likely to suffer a fall-related injury compared to those who did not
receive this intervention (Barnett, Smith, Lord, Williams & Baumand, 2003).
The Stepping On Program is a multifaceted community based falls prevention program that
focuses on improving lower limb balance and strength, with the aim of improving fall self-efficacy
and reducing the incidence of falls among older adults aged 65 and over who had a fall in the
preceding year or have a fear of falling (Stevens & Sogolow, 2008). The stepping on intervention
group reported a 31% reduction in falls 12 months after the program completion, with secondary
analysis revealing that this program is particularly effective for men (p=0.003).
By integrating movements specifically prescribed to improve balance into everyday activities, the
Lifestyle Integrated Functional Exercise (LiFE) program aims to reduce the rate of falls in high risk
older adults living at home. After 12 months follow up, there was a 31% reduction in the rate of falls
and a 29% improvement in static balance for the LiFE participants compared with control
participants (Clemson, et al., 2012).
Ideal characteristics of a falls prevention exercise program
Falls Prevention research has moved towards identifying the specific elements or characteristics
which make exercise programs successful in falls prevention. Sherrington et al. (2008) conducted
a systematic review with meta-analysis on 44 studies and showed that the greatest relative effects
of exercise on fall rates were observed in programs that safely challenge balance (exercises that
modify the base of support, reduce upper limb support and involve movements of centre of mass)
and have a high total dose of exercise (at least two hours per week or greater than 50 hours over
the trial period).
These findings are supported by Arnold, Sran, and Harrison (2008); Clemson et al. (2012) and
Sherrington, Lord, and Close (2008) and are considered as current best practice recommendations
for falls prevention (see Table 1 below). More importantly, this information is crucial as it provides
detailed criteria against which other programs or in the case of this project, recreational activities
can be assessed and deemed efficacious in improving balance and reducing risk of falls.
Personal Choice Report
September 2015
Page 10
Table 1: Ideal characteristics of a falls prevention program
Category Characteristic
Static and Dynamic Balance Involves movement of Centre of Mass (COM)
Involves movement to limits of anterior and postural sway
Challenges limits of dynamic and static stability
Involves shifting body weight from foot to foot
Involves turning and changing direction
Reduces upper limb support
Reduces size of base of support
Involves multidirectional reaching
Neuromuscular Challenges hip extension Range of Motion (ROM)
Challenges gait speed
Requires gait speed
Requires fast reaction / response time
Involves activation of hip and ankle muscles
Sensorimotor Involves movement of head
Involved moving visual targets or field
FITTIP Task oriented
High total does of exercise (>2 hours / week)
Involves movement with high repetition, usually low load, and is
progressive
Not modular in organisational type
Adapted from “Effective exercise for the prevention of falls: A systematic review and meta-analysis” by
Sherrington, C. et al., 2008, Journal of the American Geriatrics Society, 56(12), 2234 – 2243.
doi:10.1111/j.1532-5415.2008.02014.x
The George Institute for International Health & Prince of Wales Medical Research Institute (2009)
investigated the characteristics of community based physical activity falls prevention programs.
Their findings supported those of Sherrington et al. (2008) but revealed a unique outcome. They
recommended ongoing balance-challenging exercise for at least 2 hours per week; however, only
25% of visited classes and programs met these recommendations. Most (28%) were providing a
high challenge to balance but failed to meet the recommended 2 hours exercise per week or were
short term. This finding highlights the current trend of minimal evidence being integrated into
practice and supports the need for more sustainable balance challenging activities that have a
higher dose per week.
Personal Choice Report
September 2015
Page 11
Recreational Activities
Benefits of recreational activities
There are several mental and social benefits associated with involvement in recreational exercise
including reduced stress, anxiety and depression (Schwarzenegger, Chrisman, & Coleman, 2005).
In providing opportunities for older adults to socialise, recreational exercise can also reduce
feelings of alienation and loneliness, and increase self-esteem and self-efficacy.
Exercise interventions incorporating balance exercises have long been considered a viable falls
prevention initiative due to their logical and universal approach (Cho, An, & Yoo, 2014). However
as exercise programs usually require the development of a personalised program and the use of
specialised equipment, recreational exercise can serve as a promising and feasible alternative for
the maintenance of balance in community dwelling older adults, due to its ability to be personalised
to the adult’s interests, instinctive, and often does not require expensive equipment (Hutchins,
2009).
Older adults’ participation in recreational activities
Despite the well-known benefits of recreational activities for older adults, participation rates in
these activities are low. Based on the 2006 General Social Survey only 56% of WA older adults
participated in some sport or physical activity in the 12 months prior to the survey (Australian
Bureau of Statistics, 2007). This is fairly similar to national trends (49% of Australian older adults).
Interestingly, participation rates did not vary significantly based on gender (Milligan, McCormack, &
Rosenberg, 2009). However participation rates have been shown to decline after the age of 65,
from 39% of those aged 55-64 years to only 23% of those aged over 65 years (Milligan,
McCormack, & Rosenberg, 2009).
Participation rates were also higher among older adults living in non-metropolitan areas of WA
compared to metropolitan areas, 69% and 58% respectively (Amonini, Braidwood, & Joyce H,
2011; Armstrong, Bauman, & Davies, 2000). Furthermore, participation rates were higher among
older adults born in Australia compared to those born overseas (in a country where the primary
language is English), 67% and 53% respectively. That being said, for older adults who were born
in countries where English is not the main language, participation rates were even lower (i.e. 49%)
(Australian Bureau of Statistics, 2011; Australian Institute of Health and Welfare, 2007).
Walking appears to be the most popular form of recreational exercise for WA older adults (32%),
followed by lawn bowls (7%) (Amonini et al., 2011). This is consistent with national trends (Merom,
Pye, et al., 2012). Surprisingly, cycling, tennis, tai chi and yoga were the least popular activities
that Australian older adults participated in, totalling less than 5% of activities (Amonini et al., 2011).
Australian older adults tend to only participate in one type of physical activity rather than a
combination of activities (Merom, Carmen, Kamalesh, & Adrian, 2012). Interestingly, most activities
were likely to be aerobic (e.g. walking, golf, cycling, racquet sports) as opposed to strength and
flexibility based activities proven to improve balance (e.g. tai chi, yoga, dancing) (Merom, Carmen,
Kamalesh, & Adrian, 2012).
Personal Choice Report
September 2015
Page 12
Methodology
Data Sources and Searches
A literature search was conducted in December 2014 using Google Scholar to identify studies that
looked into the effects of specific recreational activities on falls prevention. PubMed, Science Direct
and Prevention of Falls Network for Dissemination (ProFouND) databases were then used to
supplement the search.
Study Selection
Published randomised trials that were conducted in older people were reviewed if recreational
activity was the primary intervention being evaluated and the outcome was; balance test
measures, number of falls or rate of falls. Trials were ineligible if non recreational activity
interventions were a major component of the intervention under evaluation.
To determine eligibility of identified trials, the primary investigator independently scanned titles and
abstracts. If it was clear that there were less than two not fully randomised studies evaluating the
effect of a particular recreational activity (e.g. table tennis) on falls prevention, the study was
excluded on the basis that there must be sufficient valid evidence to warrant review and promotion
in the latter phases of this project. This resulted in only eleven recreational activities being included
within the final document. Whilst there was a search for studies investigating the effect of cultural
activities, such as Aboriginal dance on falls prevention, the current lack of relevant studies meant
that cultural activities were excluded from review. The full articles for the remaining titles were then
obtained.
All articles were then compared and contrasted to examine the benefits and risks that are
associated with each recreational activity in relation to reducing the risk of falls.
Review Process
After internal review of the draft document, the draft document was released for broad consultation
in July 2015 to allow for comments and feedback. Upon receiving this feedback edits were made to
the document before the document was finalised in September 2015. To view a complete list of the
document reviewers please refer to the acknowledgements on page five.
Personal Choice Report
September 2015
Page 13
Literature Review
Trails included in the literature review
In total, 30 trials and 11 different recreational activities were determined as appropriate for review.
These recreation activities include aquarobics, cycling, dancing, exergaming, golf, lawn bowls,
Lifeball, tai chi, tennis, walking and yoga. The included trials involved a total of 2,232 participants.
The majority of trials were conducted on older adults living in the community; one trial was
conducted on residents in high care residential facilities (i.e. nursing homes). Six trials included
only participants who could be defined as being at high risk of falls. Most of the recreational
activities evaluated in the trials (n = 25) were conducted under supervision, with fewer than 15
participants per instructor. In most of the programs, the frequency, intensity and duration of
recreational exercise was tailored to suit each individual participant (n = 25).
Characteristics and conclusions of the trials are summarised in appendix 1.
Aquarobics
Aquarobics has been used for a long time for treating musculoskeletal disorders; however it has
only recently been linked to falls prevention due to its positive effect on flexibility, muscle strength
and balance. The majority of individuals participating in aquarobics do so in an organised
aquarobics class, which can result in a higher cost than other recreational activities due to the
overall cost involving the class and admission to the pool.
Benefits of Aquarobics for balance
Kim and O’Sullivan (2013) investigated the effect of aqua exercise therapy on preventing falls in
the elderly. The results showed that after 12 weeks of aqua exercise therapy, balance was
improved by 30%. This result supports that of Devereux, Robertson and Briffa in 2005. Resende,
Rassi and Viana (2008) also evaluated the effect of a hydrotherapy program for balance, in relation
to the risk of falls in elderly women. They reported that after 12 weeks of hydrotherapy, there was
significant improvement in participants’ balance, as assessed using the Berg Balance scale
(p<0.001) and the Timed Up & Go test (p<0.001). There was also a reduction of the scores in a
scale of risk of falls.
These findings may be explained by the fact that water is viscous; it decelerates movement and
impedes falls, which prolongs the time available for regaining posture when the body is
unbalanced. Furthermore, floating acts as a support which can increase an older adult’s
confidence and reduce their fear of falling. In this manner, individuals or more specifically, older
adults can be challenged beyond their limits of stability without fear of consequences of falls that
would occur during land-based activities (Resende et al., 2008).
Risks of Aquarobics for balance
The literature included in this review did not identify any risk to balance and/or risk to falling whilst
participating in Aquarobics.
Benefits of aquarobics for balance:
Improves balance
Reduces the scale of falls risk factors
Reduces fear of falling
Personal Choice Report
September 2015
Page 14
Cycling
With over 50% of Australian older adults undertaking their physical activity in unstructured forms
and the majority preferring to exercise alone rather than in a group, activity that is individual-based,
such as cycling, poses a promising option for older adults who are able to ride a bicycle or are
already physically active. Most people cycle for leisure in an unstructured way, which bearing the
initial cost of purchasing a bicycle allows for minimal ongoing costs.
Benefits of cycling for balance
Although it is unknown if cycling prevents falls, there is some evidence to suggest that cycling is
associated with improved balance of older adults.
Rissel, Passmore, Mason and Merom (2013) conducted two pilot studies to examine the effect of
cycling on balance among older adults. Study one investigated whether age-related declines in
balance are moderated by cycling. Their results showed that participants who had cycled in the
last month reported significantly better results on dynamic balance measures of decision time and
reaction time, 13.4% and 18.6% respectively. Study two examined whether regular cycling can
improve balance. They reported that cycling at least one hour per week was associated with 4.8-
5.8% improvements in balance (decision time and response time) and timed single leg standing.
Overall, the results suggest that cycling has a positive impact on balance, over and above what is
gained through other physical activity.
Risks of cycling for balance
The literature included in this review did not identify any risk to balance and/or risk to falling whilst
participating in cycling.
Dancing
Dancing is an instinctive type of exercise for many older adults as many have enjoyed music and
had positive experiences of dance earlier in their lives (Walls, 2012). Dancing does not require any
form of structured participation, however if participation is through a structured format participation
costs are comparative to other recreation activities.
Benefits of dancing for balance
Federici, Bellagamba, and Rocchi (2005) examined the efficacy of an exercise program based on
dance in improving balance in adults. Results showed that the exercise group had considerable
improvements in balance test results compared to the control group. Furthermore, da Silva Borges
et al. (2014) and Jeon et al. (2005) reported an increase in lower extremity strength and
significantly fewer falls post-test relative to pre-test (p<0.0001) in the dancing group after 12 weeks
of dancing in the form of foxtrot, waltz, rumba, swing, samba and bolero.
These findings could also be explained by the fact that dancing activates the basal ganglia,
responsible for motor control and learning, posture, coordination and speed of movement (Walls,
2012). In doing so, dancing preserves functional autonomy and balance, thus minimising the risk of
falls. Studies (McKinley et al., 2008; Walls, 2012) have also compared different forms of dancing
and revealed that Greek and Salsa dance had the greatest improvements in static and dynamic
balance compared to Aerobic dance.
Benefits of cycling for balance:
Improves balance
Improves reaction time
Personal Choice Report
September 2015
Page 15
Apart from the balance-related benefits of dancing, 17 out of the 20 participants in the Federici et
al. (2005) study exercise group reported great or moderate satisfaction with the dance activity. This
psychosocial benefit has important implications as satisfaction is directly correlated to adherence
to exercise (Shigematsu et al., 2002). However, the majority of the studies were conducted using
only female participants. As such, it is still somewhat unclear whether older men can derive the
same benefits from dancing as do older women (Eyigor, Karapolat, Durmaz, Ibisoglu, & Cakir,
2009; Hopkins, Murrah, Hoeger, & Rhodes, 1990; Kim, June, & Song, 2003; Young, Weeks, &
Beck, 2007). Moreover, dance exercise classes tend to be modular in organisation and often rely
on learning a fixed sequence of steps and do not always increase in intensity or complexity, thus
limiting the amount of variety and challenge. This could increase attrition rates and poses an issue
worthy of consideration when recommending this form of activity to older adults.
Risks of dancing for balance
The literature included in this review did not identify any risk to balance and/or risk to falling whilst
participating in dancing.
Exergaming
In recent years, games consoles such as Nintendo Wii and Xbox have become increasingly popular among the older adult population, particularly in nursing homes and assisted-living communities. Research has been conducted to discover the potential of exergames for balance rehabilitation and in reducing the risk of falls in older adults due to their accessibility, affordability, its ease of use and potential for in home use (Agmon et. al, 2011).
Benefits of Exergaming on balance
Brumels, Blasius, Cortright, Oumedian, and Solberg reported in 2008 that participation in Nintendo
Wii Fit games significantly reduced anterior and posterior postural sway, and a reduced deviation
from the centre of pressure, all indicating an improvement in balance. More specifically, being task
oriented and a repetitive form of training, Wii games induce neuroplasticity and thus, reduce the
risk of accidental falls and fall-related injuries (Prosperini et al., 2014).
Agmon, Perry, Phelan, Demiris, and Nguyen (2011) determined the safety and feasibility of using
Nintendo’s Wii Fit exergames to improve balance in older adults. With only 2 of the games
requiring modification for safety reasons, there was an improvement in Berg Balance scores from
49 (2.1) points to 53 (1.8) points after three months of this intervention. This finding is supported by
Gardner (2011) and Clark and Kramer (2009). However this improvement by Agmon, Perry,
Phelan, Demiris, and Nguyen may be spurious given the small sample size of seven participants
and lack of control group. That being said, the qualitative feedback from Clark and Kramer
reporting that participants rated high enjoyment immediately after exergame play and expressed
notable improvements in balance in relation to their daily activities suggests that the changes as
measured by the Berg Balance scale may be accurate. This has important implications as older
adults are more likely to adhere to participating in a recreational activity for the long term if
motivation and level of enjoyment are high. The use of exergames as balance training tools is
growing and will continue to grow with the developments of sensor technology (Van Diest, Lamoth,
Stegenga, Verkerke & Postema, 2013).
Benefits of dancing on balance:
Improves static and dynamic balance
Improves lower extremity strength
Preserves functional autonomy
Personal Choice Report
September 2015
Page 16
Risks of exergaming on balance
The literature included in this review did not identify any risk to balance and/or risk to falling whilst
participating in exergaming.
Golf
In a well-executed golf-swing, there are certain requirements that must be reached. That is, golfers
must maintain good balance and precise postural control of the head and body in relation to space
and to the limb, as well as timely coordination of their muscle activities (Tsang and Hui-Chan,
2004). Due to the equipment and playing surface requirements for golf it can be an expensive
recreational activity, particularly when starting to play.
Benefits of golf on balance
Tsang and Hui-Chan (2004) demonstrated that experienced elderly golfers had improved knee
joint proprioceptive acuity and limits of dynamic stability, when compared with the elderly control
participants. These findings have important implications as it suggests that golf could minimise the
age-related decline in these specific sensorimotor functions. Golfing requires golfers to shift their
body weight in a smooth and coordinated manner, which may potentially enhance the directional
control of their leaning trajectory.
Risks of golf on balance
The literature included in this review did not identify any risk to balance and/or risk to falling whilst
participating in golf.
Lawn bowls
Lawn bowls is very popular among older adults and is highly recommended for this age group as it
is low impact and usually occurs in a social and supportive atmosphere. However, the kind of
balance training that is provided by lawn bowls has not been specifically researched in regards to
reducing the risk of falls among older people.
Lawn bowls clubs cater for one off participants and ongoing members which can vary the costs
associated with participating. Most lawn bowl clubs offer one off participation fees for irregular
participants providing an affordable option, which includes the costs associated with using the
green and the rent of bowls for the session. If participating at a higher frequency most people opt
to become a member of a club and purchase their own bowls.
Benefits of exergaming on balance:
Reduces anterior and posterior sway
Reduces deviation from the centre of pressure
Induces neuroplasticity
Benefits of golf on balance:
Maintains balance
Improves coordination of muscle activities
Minimises the overall age-related decline in sensorimotor functions
Enhances control of leaning trajectory
Personal Choice Report
September 2015
Page 17
Benefits of lawn bowls on balance
Brooke-Wavell and Cooling (2009) compared fall-risk factors between older (60-75 year old) women who regularly participate in lawn bowls and controls. Regular bowlers were shown to have significantly lower timed-up & go test times and less sway while standing on a compliant surface. As such, long term participation in lawn bowls could help prevent frailty. One simplistic explanation for this finding is that lawn bowls maintains major joint movements and in doing so, prevents weakness and atrophy of the core and lower limb muscles that control balance (Mcgrath & Cassell, 2002).
Risks of lawn bowls on balance
The literature included in this review did not identify any risk to balance and/or risk to falling whilst
participating in lawn bowls.
Lifeball
While most ball games promote physical activity, they may not be appropriate for older adults due
to the injury risk (Barnett, Green, van Beurden, Campbell and Radvan 2009). Hence, the invention
of Lifeball, a team-based option for older adults that is played at walking pace with ball throwing
similar to netball and basketball. This game has gained increasing popularity with over 1000 older
adults participating in Lifeball per week in 73 groups in four Australian states. Lifeball has been
developed for older adults and acknowledging that many older adults have limited disposable
income most Lifeball games are run for free by the local shire or community group, while other
require a small fee to participate.
Benefits of Lifeball on balance
As Lifeball was developed to provide an opportunity for older adults to participate in a team
recreational activity that was played at a walking pace, in addition to participants gaining the
benefits associated with walking, Lifeball has the potential for participants to gain the benefits
associated with participating in a team based activity. The stop/start nature of Lifeball enables the
participants to build their static and dynamic balance in a fun environment (Barnett, Green, van
Beurden, Campbell and Radvan, 2009).
Due to the format of the game the reduced injury risk associated with the game encourages older
adults to participate and gain the health benefits associated with participating without the high level
of risk that is associated with other recreational activities.
Risks of Lifeball on balance
That being said, Barnett, Green, van Beurden, Campbell and Radvan (2009) showed that this
game is not risk-free as falls do occur during game participation. Falls are a particularly common
cause of recreation related injury which highly influenced the development of Lifeball. Falls that
have occurred while participating in Lifeball have been linked to the individual not adhering to the
Lifeball rules and recommendations.
Furthermore, this game was developed on the premise that walking is a popular exercise of choice
for older adults. In light of recent evidence suggesting that walking is not ideal for falls prevention,
due to the benefits associated with participating in Lifeball and the reduced injury risk when
Benefits of lawn bowls on balance:
Supports the maintenance of major joint movements
Prevents weakness in the core and lower limb muscles that control balance
Less sway when standing on a compliant surface
Personal Choice Report
September 2015
Page 18
compared to other team recreational activities, this novel ball game should be recommended with
caution and when participating the rules and recommendations should be followed.
Tai Chi
It is common for elderly fallers to have reduced proprioception in their lower limbs (Lord, Rogers, Howland, and Fitzpatrick, 1999). Participating in tai chi requires the individual to shift their body weight to different target positions in a smooth and coordinated manner. In order for participants to maintain their centre of mass within their base of support their balance control systems are challenged (Taylor et al., 2012). The Falls Prevention Model of Care acknowledges that systematic reviews have identified that tai chi can reduce falls by 37% (Department of Health, 2014).
When economically evaluated, tai chi serves as a feasible option to prevent falls, which has
important implications given the predicted increased cost of falls in the future.
Benefits of tai chi on balance
Wolf et al. (1996) was the first large study to assess the effect of a 15 week program of tai chi
classes that used 10 simplified movements on community dwelling older adults. Among the tai chi
class participants, after four months follow up, the risk of multiple falls was reduced by 47.5%.
Moreover, participants reported that after the study, they were better able to stop themselves from
falling by using their environment and appropriate body manoeuvres. Thus, it can be supported
that a moderate tai chi intervention can impact favourable on defined sensorimotor indices of
frailty, such as balance, as well as upon the occurrence of falls. A Cochran review into
interventions for preventing falls in older people living in the community found that tai chi classes
were the only single exercise intervention effective in reducing the risk of falling (Gillespie, 2009).
The review also concluded that tai chi as a group exercise is less effective in people at higher risk
of falling.
Li, Harmer, Fisher, and Mcauley (2004) also compared the effectiveness of a six month classical
24-Form Yang style Tai Chi on 70 year old older adults. Their results revealed that participants in
the tai chi classes had fewer falls, lower proportions of fallers and fewer fall-related injuries than
the control group. Furthermore, their risk of falling was 55% lower than that of the control group.
This trend is supported by Low, Ang, Goh, and Chew (2009) who included 24-Form Yang style Tai
Chi, Sun-style Tai Chi and synthesized forms of Tai Chi in their study, and Taylor et. al (2012)
which focused on Sun-style Tai Chi.
A study conducted by Voukelatos, et.al. in 2007 which included Sun-style Tai Chi (83% of included
Tai Chi programs were Sun-style Tai Chi), Yang-style Tai Chi and a mixture of several styles,
supports tai chi as an effective and sustainable public health intervention for falls prevention
amongst older people living in the community, with results indicating that participants risk of
multiple falls decreased by approximately 70%.
Benefits of Lifeball on balance:
Improves postural control system
Builds static and dynamic balance
Improves fitness Risks of Lifeball on balance:
Participating in a team requires awareness of other peoples movements
Potential to focus too much on the ball and the competition rather than balance
Personal Choice Report
September 2015
Page 19
As evident in the above literature, research into the benefits of tai chi has included a range of
styles of tai chi. Each style includes unique characteristics and therefore the results of each
research study is influenced by the style of tai chi used in the study.
Risks of Tai Chi on balance
The literature included in this review did not identify any risk to balance and/or risk to falling whilst
participating in tai chi.
Tennis
Extensive research has been completed relating to the numerous health benefits of tennis for
individuals at all life stages, with results supporting participating in tennis as in the majority of the
research the benefits outweighed the risks. Contrasting this, there is a lack of literature
investigating the balance related benefits experienced through tennis.
As tennis requires personal equipment there are one off expenses involved and ongoing expenses
due to the hiring of a court. However as tennis provides the opportunity to play socially or in a club
overall it is economically sustainable (Groppel & DiNubile, 2009).
Benefits of tennis on balance
Studies have suggested that tennis improves dynamic balance as it requires total control of one’s
body even while running at top speed (Groppel & DiNubile, 2009; Marks, 2006). Furthermore,
cognitive alertness and joint proprioception has been shown to be enhanced from engaging in
tennis. More importantly, these skills or abilities can be easily translated to everyday life, thus
allowing older adults to reduce their risk of falls and live independently well into their 90’s. As the
risk of injury associated with tennis is comparatively lower than other sports, it is safe to
recommend tennis to older adults in an attempt to improve balance and reduce their risk of falls.
Risks of tennis on balance
Despite tennis providing benefits to balance, there are a range of injuries that can occur while
playing tennis, particularly as a result of lifelong participation, which can then pose as a risk to the
individuals balance. Injuries to the wrist, elbow and Achilles tendon promote osteoarthritis,
tendonitis, sprains, strains and occasional fractures which can not only reduce the individuals
balance but are also health concerns (Marks, 2006).
Benefits of tai chi on balance:
Maintains centre of mass within the base of support
Develops joint proprioception in lower limbs
Improves overall balance
Reduces risk of falling
Benefits of tennis on balance:
Improves dynamic balance
Develops joint proprioception
Enhances cognitive alertness Risks of tennis on balance:
Injuries to the wrist, elbow and Achilles tendon which can promote osteoarthritis, tendonitis, sprains, strains and fractures
Personal Choice Report
September 2015
Page 20
Walking
As was previously mentioned, the majority of WA older adults (32%) choose walking as their
predominant form of exercise. While walking at, or above, 3-4 km per hour confers health benefits,
its role in falls prevention remains unclear (Voukelatos et al., 2011).
Falls are not the only important outcome for exercise trials in elderly populations, as studies have
shown that walking programs exert great benefits on fitness. As such, if falls prevention is the
primary aim, walking programs should be included only if they are in addition to other activities
more beneficial in improving balance and reducing falls risk (Asikainen et al., 2006).
Walking is the cheapest recreational activity available as it only requires supportive footwear and a safe walking environment.
Benefits of walking on balance
A 15 week walking program showed no significant effect on balance among sedentary, post-
menopausal women (Asikainen et al., 2006). However, fractionating walking into two daily
sessions was shown to be more feasible than continuous walking. The overall results of the study
were influenced by the fact that over 50% of the participants reached a maximum score in the
baseline balance testing which might have decreased the possibility to detect a real training effect.
Conversely, a study which compared the effectiveness of three different balance training
programs, including walking in women aged 50-75 years, found that all three programs improved
dynamic balance, but walking had a more significant effect on static balance (Clary, Barnes,
Bemben, Knehans, & Bemben, 2006).
Risks of walking on balance
Recent research (Murphy, Nevill, Murtagh, & Holder, 2007; Sherrington et al., 2008) has revealed
that compared to exercise programs that involve walking, programs that exclude walking are
beneficial to reducing the risk of falls. This may be due to the fact that there is increased exposure
to risk with walking, although published trials do not indicate that many falls occurred when
participants were undertaking walking programs. An alternative explanation could be that walking
utilises time that could otherwise be allocated to high level balance training.
Due to walking requiring a range of processes, including; initiating and terminating gait, changing
direction, adjusting stride length and adjusting step height walking highly challenges the postural
control system. The walker must actively consider a range of factors while walking, which if not
considered and actioned appropriately the individual is at risk of experiencing a fall.
Benefits of walking on balance:
Improves dynamic balance
Improves static balance
Develops fitness
Risks of walking on balance:
Exposure to risk
Challenges the postural control system
Personal Choice Report
September 2015
Page 21
Yoga
Over the past decade, the use of yoga to prevent falls and reduce the risk of falling in community
dwelling older adults has gained popularity (Kelley, 2013). Yoga practice has been shown to
specifically target and improve factors such as free joint mobility, appropriate timing and intensity
of muscle action, as well as normal sensory input that promote normal balance (Woollacott,
Shumway-Cook, & Nashner, 1982). The only form of equipment associated with yoga is a yoga
mat, meaning that yoga can be completed in an individual’s home with minimal expenses (Kelley,
2013). If the individual wants to participate in a yoga class the majority have admission costs
associated, however most are comparative to other recreational activities.
Benefits of yoga on balance
Zettergen, Viverito, and Lubeski (2011) conducted a pilot study with 16 participants aged 79-88.
After eight weeks of yoga, there was a statistically significant improvement on scores on balance
tests, revealing a reduced risk of falling (t=4.51; p<0.003). Brown, Koziol, and Lotz (2007) and a
pilot study conducted by Schmid, Van Puymbroeck, and Koceja (2010) support this trend as well,
with a 4% increase in static balance. Overall, participants in the yoga group reported feeling
steadier. The effect of yoga on fear of falling has also been examined. After 12 weeks of yoga,
participants reported a 6% decrease in fear of falling (Schmid, Van Puymbroeck, and Koceja,
2010).
DiBenedetto, Innes, Taylor, Rodeheaver, and Boxer (2005) evaluated the effects of yoga on gait
speed and hip extension. Although the authors of this study did not directly measure falls or falls
risk, improving gait speed and hip extension range of motion has been shown to reduce risk of
falling. As such, after eight weeks of yoga, there was a noticeable improvement in hip extension
range of motion but a non-significant increase in self-selected gait speed.
Furthermore, the importance and significant improvements in balance and fall risk associated with
incorporating specific poses into a yoga program has been researched (Brown et al., 2007;
Zettergen, Moriarty, & Zabel, 2006; Zettergen et al., 2011). More specifically, sitting and standing
positions have been shown to improve Berg Balance Scale scores and dynamic balance.
Risks of yoga on balance
The literature included in this review did not identify any risk to balance and/or risk to falling whilst
participating in yoga.
Benefits of yoga on balance:
Improves static balance
Decreases fear of falling
Improves hip extension range of motion
Personal Choice Report
September 2015
Page 22
Recommendations
This report has identified several gaps that warrant further attention.
Overall the literature search did not identify a large amount of research into the role that
recreational activities can have in falls prevention. As identified throughout this literature search,
the research shows a positive link that many recreational activities improve falls risk factors
including balance, flexibility and fear of falling. This is encouraging and further highlighting the
need research could determine if this leads to the prevention of falls.
Despite the research indicating that recreational activities have the potential to decrease an
individual’s falls risk, there is no consensus on whether older adults should be encouraged to
engage in multiple recreational activities or a single activity to elicit falls prevention benefits. Also
the ideal frequency, intensity and length of participation have not been established. Future
research into these areas would allow guidelines to be produced surrounding participating in
recreational activities as a falls prevention measure.
When deciding what type of recreational activity to become involved in an individual’s previous
experiences, preferences and views of the activity have a significant influence on what activity is
chosen. Despite this there is a current lack of evidence in the literature around the importance of
implementing strategies that adopt a person-centred approach to falls prevention. Research into
the importance of considering the impact that personal factors have on participation in recreational
activities and potential barriers /enablers to participation will support the development of a rounded
falls prevention intervention.
Research sited throughout this report suggests the importance of maintaining optimal balance
throughout the lifespan to aid in improving balance later in life. However there is minimal evidence
to support a hypothesis that participating in recreational activities in middle age can prevent falls in
older age. Despite the challenging longitudinal requirements of this type of study, the results that it
could produce would directly impact on falls prevention interventions.
This literature search identified no studies that specifically investigated the effectiveness of
recreational activities for falls prevention in culturally and linguistically diverse communities,
Indigenous populations or research into cultural activities for falls prevention, such as Aboriginal
dance. Further research into the benefits and risks of participating in recreational activities for
population subgroups would provide additional support for health professionals and community
workers when weighing up the benefits and risks associated with each recreational activity.
The research studies included within this literature search have used a variety of assessment tools
during their research which makes the comparison of results between the studies challenging. A
study into the benefits of recreational activities for balance that measures each activity using the
same criteria and assessment tools would allow for a valid comparison between the recreational
activities.
Personal Choice Report
September 2015
Page 23
Limitations
All analysis conducted throughout this literature search was from a falls prevention perspective and
therefore does not consider any other factors that impact on the benefits and risks of participating
in the recreation activity.
The inclusion criteria for the trials only related to the purpose of the trial, excluding other criteria
such as the methodology. The lack of exclusion criteria surrounding the methodology of the trials
limited the opportunities to compare the research as the; assessment tools, sample size, duration
of the trial, criteria for participant inclusion and selection pool varied between the trials included in
this literature search.
Following the collection and filtering of the research, recreation activities were included in this
literature search if at least two fully randomised studies were retrieved relating to the recreational
activity. Therefore the eleven activities included in this trial are not necessarily the best recreational
activities for minimising the age-related decline in balance; rather that there is a lack of evidence
supporting the benefits of the recreational activities excluded from this literature search.
Studies included in this literature search focus on gait and stability when measuring balance.
However the vestibular system, somatosensory system and vision also contribute to an individual’s
balance. By not recognising the role that these factors have on balance it does not provide a
complete analysis of the role that recreational activities can have on improving an individual’s
balance.
Personal Choice Report
September 2015
Page 24
Next Steps
This document is available for public access on the Stay On Your Feet® website to provide support
for health professionals and community workers when referring their clients to recreation activities
and for community members when deciding what recreational activity to participate in.
This literature search has identified a range of areas that warrant additional research to provide
further guidance to community members and health professionals on the potential benefits and
risks of recreational activity for minimising the decline in balance that can occur with ageing and
thus reducing the risk of falls.
If you require further information regarding this document please contact the team from Stay On
Your Feet® on [email protected] or 1300 30 35 40.
Personal Choice Report
September 2015
Page 25
Glossary
Term Definition
Alternate step test measures lateral stability by timing the duration taken to alternatively place
the left and right foot eight times onto a step 18cm high
Ambulation the ability to walk independently from place to place with or without an
assistive device
Arterial sway rhythmic movement backwards and forwards
Atrophy gradual decrease in a body part or tissue
Berg Balance test assesses performance in 14 functional subtests to measure balance
among people with impaired balance.
CaLD communities Culturally and linguistically diverse communities
Community
dwelling
residing in private housing within the community
Dynamic stability the ability to return to a previously established steady state
Fall ‘Inadvertently coming to rest on the ground, floor or other lower level,
excluding intentional change in position to rest in furniture, wall or other
objects’ (Gillespie, 2009).
Falls Risk for Older
People – Com tool
covering 13 risk factors this falls risk assessment tool includes 26
questions with either dichotomous (0-1) or ordinal (0-3) scoring, with a
score higher than 18 indicating a high risk of falls.
Frailty a clinical term that describes the presence of multisystem impairment and
expanding vulnerability (Rockwood, 2005).
Gait a manner of walking
Hospitalisations total number of admissions to hospital
Health
Professional
a person employed in a field of health in a clinical, allied health or
population-based context. (Fransen, 2007).
ICCWA Injury Control Council of Western Australia
Intervention an action that attempts to modify the outcome
Literature search methodical search through published literature to identify relevant and
validated references relating to a particular topic
Meta-analysis statistical technique for combining findings from different studies in the
hope of identifying patterns among the studies
Personal Choice Report
September 2015
Page 26
Term Definition
Modifiable risk
factor
conditions that increase your risk of developing a disease where methods
can be taken to change them
Neuroplasticity the ability for the brain to restructure itself
Older adult Non-Aboriginal person aged 60 years or older; or an Aboriginal person
aged 45 years or older
Person-centred places the individual at the centre of the approach
Postural sway rhythmic movement side to side
Practitioner an individual who practices a skilled profession or occupation
Randomised trial a study where participants are randomly assigned to different interventions
Range of motion the movement potential of a specific joint or body part
Recreational
activities
activities that are participated in for leisure that are fun, cognitive and/or
physical
Static stability the ability to maintain upright equilibrium at rest
Timed Up & Go test provide a global indication of steadiness by timing the duration taken for
the subject to stand, walk 3 meters, turn around and walk back to the chair
and sit down
WHO World Health Organisation
Personal Choice Report
September 2015
Page 27
References
Agmon, M., Perry, C. K., Phelan, E., Demiris, G., & Nguyen, H. Q. (2011). A Pilot Study of Wii Fit Exergames to Improve Balance in Older Adults. Journal of Geriatric Physical Therapy. doi:10.1519/JPT.0b013e3182191d98
American Geriatrics Society and British Geriatrics Society. (2011). Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of American Geriatric Society, 59(1), 148–157.
Amonini, C., Braidwood, S., & Joyce H. (2011). 2011 Profile of WA Older adults: Current Issues and Projected Trends (pp. 1–75).
Armstrong, T., Bauman, A., & Davies, J. (2000). Physical activity patterns of Australian adults (pp. 1–82).
Arnold, C., Sran, M., & Harrison, E. (2008). Exercise for fall risk reduction in community-dwelling older adults: a systematic review. Physiotherapy Canada. Physiotherapie Canada, 60(4), 358–372. doi:10.3138/physio.60.4.358
Asikainen, T., Suni, J. H., Pasanen, M. E., Oja, P., Rinne, M. B., Miilunpalo, S. I., … Vuori, I. M. (2006). Effect of Brisk Walking in 1 or 2 Daily Bouts and Moderate Resistance Training on Lower- Extremity Muscle Strength , Balance , and Walking Performance in Women Who Recently Went Through Menopause : A Randomized , Controlled Trial. Physical Therapy, 86(7), 912–923.
Australian Bureau of Statistics. (2007). Participation in Sports and Physical Recreation Australia 2005-06 (pp. 1–48).
Australian Bureau of Statistics. (2011). Australian Social Trends: Sport and Physical Recreation (pp. 1–10).
Australian Commission on Safety and Quality in Healthcare. (2009). Preventing Falls and Harm From Falls in Older People. Australian Community Care (pp. 1–202).
Australian Institute of Health and Welfare. (2007). Older Australia at a glance (pp. 1–226).
Australian Institute of Health and Welfare. Australia’s Health 2012, in Australian’s health Series
2012. Canberra: Australian Institute of Health and Welfare.
Barnett, L., Green, S., van Beurden, E., Campbell, E., & Radvan, D. (2009). Older people playing ball: What is the risk of falling and injury? Journal of Science and Medicine in Sport, 12(1), 177–183. doi:10.1016/j.jsams.2007.12.007
Barnett, L., Smith, B., Lord, S. R., Williams, M., & Baumand, A. (2003). Community-based group exercise improves balance and reduces falls in at-risk older people: A systematic randomised controlled trial. Age and Ageing, 32(4), 407–414.
Barry, E., Galvin, R., Keogh, C., Horgan, F., & Fahey, T. (2014). Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta- analysis. BioMed Central Geriatrics, 14(1), 1–14. doi:10.1186/1471-2318-14-14
Personal Choice Report
September 2015
Page 28
Berg, K., Wood-Dauphinee, S., Williams, J., & Maki, B. (1992). Measuring balance in the elderly: validation of an instrument. Canadian Journal of Public Health, 83(2), 7–11.
Brooke-Wavell, K., & Cooling, V. C. (2009). Fall risk factors in older female lawn bowls players and controls. Journal of Aging and Physical Activity, 17(1), 123–130.
Brown, K. D., Koziol, J. A., & Lotz, M. (2007). A Yoga-based exercise program to reduce the risk of falls in older adults: A pilot and feasibility study. Letters to the Editor. doi:10.1089/acm.2008.0092
Brumels, K. a., Blasius, T., Cortright, T., Oumedian, D., & Solberg, B. (2008). Comparison of efficacy between traditional and video game based balance programs. Clinical Kinesiology, 62(4), 26–31.
Clark, R., & Kramer, T. (2009). Clinical use of Nintendo Wii bowling simulation to decrease fall risk in an elderly resident of a nursing home: a case report. Journal of Geriatric Physical Therapy, 32(4), 174–180. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20469567
Clary, S., Barnes, C., Bemben, D., Knehans, A., & Bemben, M. (2006). Effects of ballates, step aerobics, and walking on balance in women aged 50-75 years. Journal of Sports Science and Medicine, 5(3), 390–399.
Clemson, L., Fiatarone Singh, M. a., Bundy, A., Cumming, R. G., Manollaras, K., O’Loughlin, P., & Black, D. (2012). Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): randomised parallel trial. British Medical Journal, 345, 1–15. doi:10.1136/bmj.e4547
Cumming, R. G., Salkeld, G., Thomas, M., & Szonyi, G. (2000). Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission. Journal of Gerontology : Biological Sciences & Medical Sciences, 55(5), 299–305.
Da Silva Borges, E. G., de Souza Vale, R. G., Cader, S. A., Leal, S., Miguel, F., Pernambuco, C. S., & Dantas, E. H. M. (2014). Postural balance and falls in elderly nursing home residents enrolled in a ballroom dancing program. Archives of Gerontology and Geriatrics, 59(2), 312–316. doi:10.1016/j.archger.2014.03.013
Department of Health, Western Australia. Falls Prevention Model of Care. Perth: Health Strategy and Networks, Department of Health, Western Australian; 2014.
Department of Health, Western Australia. (2015). Specific health condition analysis. Accidental falls hospitalisations by external cause (injury and poisoning) – Western Australia State.
Devereux, K., Robertson, D., & Briffa, N. K. (2005). Effects of a water-based program on women 65 years and over : A randomised controlled trial. Australian Journal of Physiotherapy, 51, 102–108.
DiBenedetto, M., Innes, K. E., Taylor, A. G., Rodeheaver, P. F., & Boxer, J. A. (2005). Effect of a gentle Iyengar yoga program on gait in the elderly: An explanatory study. Archives of Physical Medicine and Rehabilitation, 86(1), 1830–1837.
Downs, S., Marquez, J., & Chiarelli, P. (2014). Normative scores on the Berg Balance Scale decline after age 70 years in healthy community-dwelling people: A systematic review. Journal of Physiotherapy, 60(2), 85–89. doi:10.1016/j.jphys.2014.01.002
Personal Choice Report
September 2015
Page 29
Eyigor, S., Karapolat, H., Durmaz, B., Ibisoglu, U., & Cakir, S. (2009). A randomised controlled trial of Turkish folklore dance on the physical performance, balance, depression and quality of life in older women. Archives of Gerontology and Geriatrics, 48(1), 84–88.
Federici, A., Bellagamba, S., & Rocchi, M. B. (2005). Does dance-based training improve balance in adult and young old subjects? A pilot randomised controlled trial. Aging Clinical and Experimental Research, 17(5), 385–389. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16392413
Fransen, M., et al. (2007). A Randomised Control Trial Of 200 Subjects Comparing Tai Chi, Hydrotherapy And Control, To Measure Improvement In Pain, Physical Function, Muscular Strength And Walking Capacity. Arthritis Care and Research. 57(3), 407-414.
Gardner, B. (2011). Effectiveness of the Nintendo Wii Fit games on the balance of a community-dwelling older adult in Eastern North Carolina. East Carolina University.
Gillespie, L.D., et al. (2009). Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews. 15 (2).
Groppel, J., & DiNubile, N. (2009). Tennis: For the Health of It! The Physician and Sports Medicine, 37(2), 40–50.
Hutchins, K. (2009). Exercise vs Recreation. RenEx (pp. 1–4).
Jeon, M. Y., Bark, E. S., Lee, E. G., Im, J. S., Jeong, B. S., & Choe, E. S. (2005). The effects of a Korean traditional dance movement program in elderly women. Taehan Kanho Hakhoe Chi, 35(7), 1268–1276.
Kelley, K. (2013). Yoga for Prevention of fall. Journal of Yoga & Physical Therapy, 3(2), 1–2. doi:10.4172/2157-7595.1000133
Kim, C. G., June, K. J., & Song, R. (2003). Effects of health promotion program on cardiovascular risk factors, health behaviours, and life satisfaction in instituitionalised elderly women. International Journal of Nursing Studies, 40(4), 375–381.
Kim, S. B., & O’Sullivan, D. M. (2013). Effects of Aqua Aerobic Therapy Exercise for Older Adults on Muscular Strength , Agility and Balance to Prevent Falling during Gait. Journal of Physical Therapy Science, 25(8), 923–927.
Li, F., Harmer, P., Fisher, K. J., & Mcauley, E. (2004). Tai Chi: Improving functional balance and predicting subsequent falls in older persons. Medicine and Science in Sports and Exercise, 36(12), 2046–2052. doi:10.1249/01.MSS.0000147590.54632.E7
Lord, S. R., Rogers, M. W., Howland, A., & Fitzpatrick, R. (1999). Lateral stability, sensorimotor function and falls in older people. Journal of American Geriatric Society, 47(1), 1077–1081.
Low, S., Ang, L. W., Goh, K. S., & Chew, S. K. (2009). A systematic review of the effectiveness of Tai Chi on fall reduction among the elderly. Archives of Gerontology and Geriatrics, 48(3), 325–331. doi:10.1016/j.archger.2008.02.018
Marks, B. L. (2006). Health benefits for veteran (senior) tennis players. British Journal of Sports Medicine, 40(5), 469–476. doi:10.1136/bjsm.2005.024877
Personal Choice Report
September 2015
Page 30
Mcgrath, A., & Cassell, E. (2002). ROLLING INJURIES OUT OF LAWN BOWLS : A review of the literature (pp. 1–51). Melbourne.
McKinley, P., Jacobson, A., Leroux, A., Bednarczyk, V., Rossignol, M., & Fung, J. (2008). Effect of a community-based argentine tango dance program on functional balance and confidence in older adults. Journal of Aging and Physical Activity, 16(4), 435–453.
Merom, D., Carmen, C., Kamalesh, V., & Adrian, B. (2012). How diverse was the leisure time physical activity of older Australians over the past decade? Journal of Science and Medicine in Sport, 15(3), 213–219. doi:10.1016/j.jsams.2011.10.009
Merom, D., Pye, V., Macniven, R., van der Ploeg, H., Milat, A., Sherrington, C., … Bauman, A. (2012). Prevalence and correlates of participation in fall prevention exercise/physical activity by older adults. Preventive Medicine, 55(6), 613–617. doi:10.1016/j.ypmed.2012.10.001
Milligan, R., McCormack, G. R., & Rosenberg, M. (2009a). Results from the 2006 WA Physical Activity Survey: Key Findings by Age (pp. 1–2). Perth.
Milligan, R., McCormack, G. R., & Rosenberg, M. (2009b). Results from the 2006 WA Physical Activity Survey: Key Findings for ages 60+ years (pp. 1–2).
Moller, J. (2003). Projected costs of fall related injury to older persons due to demographic change in Australia (pp. 1–22).
Murphy, M. H., Nevill, A. M., Murtagh, E. M., & Holder, R. L. (2007). The effect of walking on fitness, fatness and resting blood pressure: a meta-analysis of randomised, controlled trials. Prev Med, 44(5), 377–385.
National Ageing Research Institute. (2006). National physical activity recommendations for older Australians: Discussion Document (pp. 1–165).
Prosperini, L., Fanelli, F., Petsas, N., Sbardella, E., Tona, F., Raz, E., … Pantano, P. (2014). Multiple Sclerosis: Changes in the Microarchitecture of White Matter Tracts after training with Wii balance board. Radiology, 1–2.
Resende, S. M., Rassi, C. M., & Viana, F. P. (2008). Effects of hydrotherapy in balance and prevention of falls among elderly women. Rev Bras Fisioter, 12(1), 57–63.
Rissel, C., Passmore, E., Mason, C., & Merom, D. (2013). Two pilot studies of the effect of bicycling on balance and leg strength among older adults. Journal of Environmental and Public Health, 2013.
Rockwood, K. (2005). Frailty and its definition: a worthy challenge. Journal of the American Geriatrics Society. 53(6). 1069 - 1070. DOI 10.1111/j.1532-5415.2005.53312.x
Rubenstein, L. Z., & Josephson, K. R. (2002). The epidemiology of falls and syncope. Clinics in Geriatric Medicine, 18, 141–158. doi:10.1016/S0749-0690(02)00002-2
Rhayun, S., Eun-ok, L., Lam, P., Sangcheol, B. (2003). Effects of tai chi exercise on pain,
balance, muscle strength, and physical functioning in older women with osteoarthritis: A
randomized clinical trial. Journal of Rheumatology September. Retrieved from:
www.jrheum.com/abstracts/abstracts03/2039.html
Personal Choice Report
September 2015
Page 31
Schmid, A. A., Van Puymbroeck, M., & Koceja, D. M. (2010). Effect of a 12-Week Yoga Intervention on Fear of Falling and Balance in Older Adults : A Pilot Study. Archives of Physical Medicine and Rehabilitation, 91(4), 576–583. doi:10.1016/j.apmr.2009.12.018
Schwarzenegger, A., Chrisman, M., & Coleman, R. (2005). The Health and Social Benefits of Recreation (pp. 1–48).
Sherrington, C., Lord, S. R., & Close, J. C. T. (2008). Best-practice recommendations for physical activity to prevent falls in older adults : a rapid review (pp. 1–33).
Sherrington, C., Whitney, J. C., Lord, S. R., Herbert, R. D., Cumming, R. G., & Close, J. C. T. (2008). Effective exercise for the prevention of falls: A systematic review and meta-analysis. Journal of the American Geriatrics Society, 56(12), 2234–2243. doi:10.1111/j.1532-5415.2008.02014.x
Shigematsu, R., Chang, M., Yabushita, N., Sakai, T., Nakagaichi, M., Nho, H., & Tanaka, K. (2002). Dance-based aerobic exercise may improve indices of falling risk in older women. Age and Ageing, 31(4), 261–266.
Stevens, J. A., & Sogolow, E. D. (2008). Preventing Falls: What Works. In A CDC Compendium of Effective Community-Based Interventions from Around the World.
Taylor, D., Hale, L., Schluter, P., Waters, D. L., Binns, E. E., McCracken, H., … Wolf, S. L. (2012). Effectiveness of tai chi as a community-based falls prevention intervention: a randomized controlled trial. Journal of the American Geriatrics Society, 60(5), 841–8. doi:10.1111/j.1532-5415.2012.03928.x
The George Institute for International Health, & Prince of Wales Medical Research Institute. (2009). Characteristics of NSW Area Health Service Physical Activity Falls Prevention Programs (pp. 1–60).
Tsang, W. W. N., & Hui-Chan, C. W. Y. (2004). Effects of Exercise on Joint Sense and Balance in Elderly Men: Tai Chi versus Golf. Medicine and Science in Sports and Exercise, 36(4), 658–667. doi:10.1249/01.MSS.0000122077.87090.2E
Van Diest, M., Lamoth, C., Stegenga, J., Verkerke, G. & Postema, K. (2013). Exergaming for
balance training of elderly: state of the art and future developments. Journal of
NeuroEngineering and Rehabilitation, 10(101). doi:10.1186/1743-0003-10-101
Voukelatos, A., Merom, D., Rissel, C., Sherrington, C., Watson, W., & Waller, K. (2011). The effect of walking on falls in older people: the “Easy Steps to Health” randomized controlled trial study protocol. BMC Public Health, 11(1), 888. doi:10.1186/1471-2458-11-888
Voukelatos, A. et al. (2007). A Randomized, Controlled Trial of tai chi for the Prevention of Falls: The Central Sydney tai chi Trial. Journal of American Geriatric Society 55(1185 - 1191).
Walls, A. (2012). Effectiveness of dance for improving balance in healthy elderly adults: An evidence-based review (pp. 1–50).
Wolf, S. L., Barnhart, H. X., Kutner, N. G., McNeely, E., Coogler, C., & Xu, T. (1996). Reducing frailty and falls in older persons: an investigation of Tai Chi and computerised balance training. Atlanta FICSIT Group. Frailty and Injuries: Cooperative Studies of Intervention Techniques. Journal of American Geriatric Society, 44(5), 489–497. Retrieved from
Personal Choice Report
September 2015
Page 32
http://www.ncbi.nlm.nih.gov/pubmed/8617895 (World Health Organisation, Global Age Friendly Cities: A Guide, 2007)
Woollacott, M. H., Shumway-Cook, A., & Nashner, L. (1982). Postural reflexes and aging. In J. Mortimer, F. J. Pirozzolo, & G. Maletta (Eds.), The Aging Motor System (pp. 98–119).
Young, C. M., Weeks, B. K., & Beck B R. (2007). Simple, novel physical activity maintains proximal femur bone mineral density and improves muscle strength and balance in sedentary, postmenopausal Caucasian women. Osteoporosis International, 18(10), 1379–1387.
Zettergen, K., Moriarty, E., & Zabel, A. (2006). The effectiveness of therapeutic yoga on community dwelling older adults with and without balance deficits. Journal of Neurology, 29(1), 215–216.
Zettergen, K., Viverito, J., & Lubeski, J. (2011). Effects of a yoga program on postural control, mobility and gait speed in community living older adults: A pilot study. Journal of Geriatric Physical Therapy, 34(1), 88–94.
Personal Choice Report
September 2015
Page 33
Appendices
Appendix 1: Summary table of included trials (n=30) showing sample size, balance tests used, results, strengths, limitations and conclusions
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Aquarobics Devereaux et
al. (2005)
50 >65
Women
Diagnosis of
Osteopenia/
Osteoporosis
Step test.
2 x 1 hour/week
for 10 weeks
Mean between group
differences in balance
1.7 (0.9 to 2.6) and 2.1
(1.1 to 3.1) steps on
the left and right sides
respectively
Offers plausible
explanation behind
benefits of water
based activity on
balance.
Relative short term
duration of study
Potential sampling
bias during
recruitment process
Not double blinded
trial
Water-based
exercise
produced
significant
changes in
balance in this
group of
community-
dwelling women
Aquarobics Resende et
al. (2008)
25 72.60 ± 7.11
Women
Berg Balance
Scale; Timed Up
& Go.
2 x 40min
sessions/week
for 12 weeks
Improvement in Berg
Balance scale scores
(p<0.001), Timed Up &
Go test (p<0.001),
reduction of the scores
in a scale of risk of
falls (p<0.001).
Three distinct
phases with
specific session
timelines within
each, which
allowed for
adaption to
aquarobics
Low sensitivity of
Berg Balance Scale
affects ability to
predict risk of falls
Small sample size
No control group
This hydrotherapy
program for
balance gave rise
to an increase in
balance and a
possible reduction
in the risk of falls
among these
aged women
Personal Choice Report
September 2015
Page 34
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Aquarobics Kim &
O’Sullivan
(2013)
15 65-77
Women
1hr 3 times a
week
Whole body dual
energy X-ray
absorptiometry
Cybex
Balance (s)
Expt 2.41
±2.2
9
3.14
±1.5
Cont 6.8±
4.71
4.77
±3.8
5
Considered
biomechanical and
physiological
factors affecting
gait
Small sample size
Gender imbalance
Only those with
high bone density
were included
therefore not
representative of
older female
population.
Aqua aerobic
therapy is an
effective exercise
method for
training older
adults to reduce
their risk of falling
Cycling Rissel et al
(2013)
43
44-79
Cycled for
preceding
month
Choice Stepping
Reaction Time
test
Leg strength test
Timed single leg
standing
13.4% (p=0.008) and
18.6% (p=0.050)
improvement in
decision time and
reaction time
respectively
Pilot studies
Range of tests
completed
Small sample size
Lack of comparison
group
Cycling by healthy
older adults
appears
promising for
improving risk
factors for falls
18
49 - 72 Same as above
1 hour / week for
12 weeks
4.8 – 5.8% (0.031
<p<0.058)
improvements in
decision time and
response time and
timed single leg
standing
Personal Choice Report
September 2015
Page 35
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Dancing Frederici et
al. (2005)
40 58-68 Sit up and go
balance tests
Significant
improvement in
balance post dancing
intervention.
17/20 participants in
dancing group
reported great or
moderate satisfaction
with dance activity.
3 month
intervention
Revealed
interesting
psychosocial
benefits of dancing
Short intervention
Lack of follow up
Small age range
Physical activity
based on dance
may improve
balance and be
useful tool in
reducing risk of
falling in the
elderly.
Dancing Shigematsu
et al. (2002)
38 72-87
Women
Dancing for 60
minutes 3
times a week
for 12 weeks
Single leg
balance with
eyes
open/closed,
functional reach,
3 minute walking
distance.
Significant
improvements in single
leg balance with eyes
open and closed
(p=0.03), functional
reach (p=0.01) and 3
min walk (p=0.03)
Simple tests used
to measure main
outcomes
Lack of measures
of falls or number of
participants who fell
Short intervention
Lack of follow up
Dance based
aerobic exercises
designed
specifically for
women can
improve selected
components of
balance and
locomotion,
thereby
attenuating risk of
falls
Personal Choice Report
September 2015
Page 36
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Dancing Gomes da
Silva Borges
et al. (2013)
59 60-76
Sedentary
Residents of
long stay
institutions
Ballroom
dancing 3 x 50
mins sessions
on alternate
days of the
week for 12
weeks
Lizard
stabilometric
and
posturometric
platform
Participants in the
dancing group
reported reduction in
lower limb weight
distribution and also
experienced
significantly fewer falls
post test relative to pre
test (p<0.0001). This
improvement not
observed in control
group.
Specified type of
dancing and dance
moves
High reliability of
platform method.
Lack of blinding
assessment.
Short intervention
Lack of follow up
Ballroom dancing
can be used to
improve balance
for elderly people
living in long term
institutions.
Dancing McKinley et
al. (2008)
30 62-91 Activity specific
Balance
Confidence
Scale and sit-to-
stand.
Two hours of
tango dancing
two times a
week for 10
weeks
Two way repeated
measures ANOVAs
indicated main effect
for time on all
measures (p<0.01) for
tango dancing group.
Strict inclusion and
exclusion criteria
lead to a similar
sample group
Preliminary results
Small sample size
Short intervention.
Tango dancing
may elicit
improvements in
balance skills in
elderly at risk of
falls
Personal Choice Report
September 2015
Page 37
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Dancing Walls (2013) 4 RCT’s that
met inclusion
criteria
Dynamic and
static balance
measures used
Statistically significant
improvements in
dynamic (effect
size=0.69) and static
balance (effect
size=0.29) measures
based on fixed effect
model.
RCT and quasi
experimental
Poor quality RCT’s
No long term follow
up
Limited databases
utilised
Dance improves
balance in healthy
elderly adults
compared to
usual activities
Dancing Keogh et al.
(2009)
18 15 training and
3 cross
sectional
studies that
met inclusion
criteria
Body
composition,
VO2max, sit to
stand, postural
stability,
dynamic balance
and gait speed
measures were
used
Grade B: elderly can
improve their aerobic
power, strength,
balance, lower body
muscle endurance and
gait through dancing.
Grade C: dancing
might improve older
adults’ bone mineral
density as well as
reduce prevalence of
falls
First to review
physical benefits of
dancing for healthy
older adults
Small number of
studies
Lack of variety of
dance forms used
in the studies
Predominance of
female participants
in studies
Dancing has an
effect on balance
and falls
prevalence in the
elderly population.
Personal Choice Report
September 2015
Page 38
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Exergaming Agmon et al.
(2011)
7 84 years old
Existing
impaired
balance
Care
retirement
communities
30 mins 3
times a week
for 3 months
Berg Balance
scores
4m timed walk
test
Physical activity
enjoyment scale
4 different
exergames-
basic step,
soccer heading,
ski slalom, table
tilt
Berg balance scores
increased from 49 to
53 points (p=0.017).
Walking speed
increased from 1.04 to
1.33m/s (p=0.018)
Higher rating of
enjoyment immediately
after exergame play.
Participants
received
individualised
instructions during
at least five home
visits.
Played four
exergames in their
homes for at least
30 minutes 3 times
a week for 3
months and
received weekly
telephone follow-
up.
Excluded large
number of
prospective
participants if they
had chronic
conditions or
deficits.
Optimal training
dose could not be
determined as
duration and
frequency of game
play was
inaccessible from
console
Lack of control
group
Use of Wii-Fit for
limited supervised
balance training
at home was a
safe and feasible
option to promote
health in older
adult populations.
Personal Choice Report
September 2015
Page 39
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Exergaming Clark &
Kraemer
(2009)
1 89 years old
Diagnosed
with
unspecified
balance
disorder and
history of falls
Berg Balance
scores
Dynamic Gait
Index
Timed Up and
Go test
Nintendo Wii
bowling for 6
one hour
sessions
BBS improved by 5
points
DGI improved by 2
points
TUG improved from
14.9 to 10.5 sec
Accessible
resource
Required minimal
prompts from the
supervisor once the
technique was
mastered
The action required
the vestibular
system to register
linear acceleration
and changes in
gravitational force
Use of only one
individual.
Self-reported
measures
Nintendo Wii
bowling
simulation may
have decreased
fall risk
Exergaming Prosperini et
al. (2014)
27 Multiple
Sclerosis
patients
Diffusion tensor
imaging MRI
technique
12 week
intervention
using Wii
balance board
based visual
feedback
training
Task oriented and
repetitive training, as
in Wii balance board,
aimed at managing a
specific symptom is
highly efective and
induces brain
plasticity.
One of the first
studies to
determine the
mechanism behind
Wii games efficacy
for falls prevention.
Use of non-
conventional DTI
technique allowed
detailed analysis of
white matter tracts.
Short intervention
period
Lack of follow up
Use of clinical
population
Wii balance board
appears to show
favourable
changes in brain
connections
associated with
balance and
movement
Personal Choice Report
September 2015
Page 40
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Exergaming Brumels et
al. (2008)
25 18-24 Star Excursion
balance testing
and force plate
data.
Wii Fit 3
times/week for 4
weeks
Postural sway
reduction for average
deviation on the y axis
observed (p=0.043).
First to examine
efficacy of video
game based
balance programs
Age group
Lack of follow up
Short intervention
period
Safe to prescribe
Wii Fit as a way to
improve physical
performance and
patient
compliance when
balance
improvement is
clinical treatment
goal
Personal Choice Report
September 2015
Page 41
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Golf Tsang & Hui-
Chan (2004)
47 Experienced
tai chi
practitioners
(>1.5
hours/week for
past 3 years)
Experienced
golfers (>1.5
hours/week for
past 3 years)
Healthy elderly
subjects
Young
university
students
All males
Passive knee
joint
repositioning
test
Limits of stability
test
Tai chi:
Absolute angle error =
1.7 ± 1.3. Reaction
time = 0.8 ± 0.1
(p<0.0001)
Golfers:
Absolute angle error =
1.3 ± 0.7. Reaction
time = 0.8 ± 0.2
(p<0.001)
Healthy elderly:
Absolute angle error =
3.9 ± 3.1. Reaction
time = 1.0 ± 0.3
(p<0.001)
Young students:
Absolute angle error =
1.1 ± 0.5. Reaction
time = 0.5 ± 0.1
(p<0.001)
Considered
different abilities
Thorough
examination of joint
flexibility
Exclusion criteria
Small sample size
in each group
Gender imbalance
Cross-sectional
design
Both experienced
tai chi
practitioners and
golfers had
improved joint
proprioceptive
acuity and
dynamic standing
balance control,
despite the known
ageing effects in
these specific
sensorimotor
functions.
Personal Choice Report
September 2015
Page 42
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Lawn Bowls Brooke-
Wavell &
Cooling
(2009)
74 60-75
Women
Timed up and go
scores
Postural stability
Lower timed-up & go
test times and less
sway while standing
on a compliant surface
Regular bowlers
and control
participants were
similar in regard to
mean age, height,
and weight
Small sample size
Lack of follow up
Gender imbalance
Long term
participation in
lawn bowls could
help prevent
frailty
Lifeball Barnett et al.
(2009)
284 40-96;
238/284
Women
Self-reported
surveys
20 participants (7.6%)
had a Lifeball fall
equating to a fall rate
of 2.8 per 1000 hours
of participation
Sample from a
large diverse
geographical
region; has
frequency and
duration of play
(1.25 hours)
Self-report bias
Intensity of play not
documented
Lifeball not risk-
free as falls do
occur during
game
participation
Tai Chi Li et al.
(2005)
256 70-92
Healthy,
physically
inactive
Berg Balance
Scale
Dynamic Gait
Index
Functional reach
60 mins 3
times/week for
six months
For tai chi group, post
intervention, risk of
falls was 55% lower
than that of the control
group.
Also significant
improvements in all
measures of functional
balance, physical
performance and
reduced fear of falling.
Appropriate
inclusion criteria
Experienced
trainers running the
activities
Statistical analysis
of the results
Structured sessions
Possibility of
experimenter bias
as not double blind
protocol
Tests for limits of
stability and
muscular strength
not used, thus
elucidating other
possible
mechanisms by
which tai chi
improves balance
Improved
functional balance
through tai chi is
associated with
subsequent
reductions in fall
frequency in older
persons.
Personal Choice Report
September 2015
Page 43
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Tai Chi Taylor et al.
(2012)
684 Mean age
74.5
73% female
>1 falls risk
factor
Timed Up n Go
test
Step test
Once a week for
20 weeks
Adjusted incident rate
ratio (IRR) for falls was
no signifcantly different
between the tai chi
group and low level
exercise group
(IRR=1.05).
Improvement in step
test (p<0.001) but not
TUG (p=0.54)
Multiple instructors
delivered the
intervention, thus
high ecological
validity as it follows
current delivery of
tai chi programs
Tai chi not
compared with
inactive group or
control group.
Potential bias as
participants may
have been aware
that ACC has
funded research
and given positive
responses as
means to ensure
ongoing funding of
the program.
No difference in
falls rates
between the
groups, with falls
reducing similarly
(mean= 58%)
over the 17 month
follow up period.
Personal Choice Report
September 2015
Page 44
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Tai Chi Wolf et al.
(1996)
200 Mean age:
76.2
Community
dwelling
elderly
Strength,
flexibility,
endurance, body
composition
ADL’s
Fear of falling
questionnaire,
CES-D scale
10 simplified
movements for
15 weeks
Grip strength declined
in all groups, and
lower extremity ROM
showed limited but
statistically significant
changes.
Fear of falling
responses reduced
post intervention
(p=0.046).
Among tai chi
participants, after four
month follow up, risk of
multiple falls reduced
by 47.5%.
Large number and
variety of tests
Considered
biomedical,
functional and
psychosocial
wellbeing
Can only be
generalised to
community dwelling
elderly with similar
level of mobility and
fitness
Uneven ratio of
males and females
Moderate tai chi
intervention can
impact favourably
on defined
biomedical and
psychosocial
indices of frailty
as well as upon
occurrence of
falls.
Personal Choice Report
September 2015
Page 45
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Tai Chi Voukelatos,
A., et al,
2007
702 Community
dwelling older
people
Confidence
questionnaire
Strength,
balance and
flexibility
Involvement in
the program
80% of the participants
did the Tai Chi for
Arthritis program
Tai Chi for Arthritis
significantly reduced
the number of falls.
Tai Chi for Arthritis
significantly reduced
the risk of multiple falls
by approximately 70%.
Largest fall
prevention study in
the world involved
16 week trial
Used existing
community facilities
Study population
was a fairly robust
group with a mean
age of 69 and most
participants rated
their health as
good, very good or
excellent. This
limits the results to
the study to young
groups of relatively
healthy older
people
Participation in
weekly
community-based
tai chi classes can
reduce falls in
relatively healthy,
community-
dwelling older
people.
The study
suggests that Tai
Chi for Arthritis is
an effective and
sustainable public
health
intervention for
falls prevention
for older people
living in the
community
Personal Choice Report
September 2015
Page 46
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Tai Chi Rhayun, S.,
Eun-ok, L.,
Lam, P.,
Sangcheol,
B., 2003
72 Older women
with
osteoarthritis
Homogeneity
test
Physical
symptoms and
fitness
Body mass
index
Cardiovascular
functioning
Perceived
difficulties in
physical
functioning
The experimental
group perceived
significantly less pain
(t = –2.19, p = 0.034)
and stiffness (t = –
2.13, p = 0.039) in
their joints, and
reported fewer
perceived difficulties in
physical functioning (t
= –2.81, p = 0.008),
In the physical fitness
test, there were
significant
improvements in
balance (t = 3.34, p =
0.002) and abdominal
muscle strength (t =
2.74, p = 0.009) for the
tai chi exercise group.
No significant group
differences in
demographic data
and pre-set
measure
Targeted at women
with osteoarthritis
41% drop out rate
Older women with
OA were able to
safely perform the
12 forms of Sun-
style tai chi
exercise for 12
weeks, and this
was effective in
improving their
arthritic
symptoms,
balance, and
physical
functioning.
Personal Choice Report
September 2015
Page 47
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Tennis Marks (2006) NA Ovid
databases
1966-2005
NA Improved dynamic
balance, cognitive
alertness, joint
proprioception.
Risk of injury
comparatively lower
than other sports.
This review
elucidates the
impact that lifetime
tennis participation
has had on various
health indices.
Based upon the
pitfalls of the
historical tennis
research, this study
provides
recommendations
for designing well
controlled future
research studies
investigating
lifelong tennis
benefits.
Lack of non-
confounded
longitudinal
experimental
research, isolating
tennis as factor for
improved
physiological
outcomes.
Safe to
recommend
tennis to older
adults in an
attempt to
improve balance
and reduce their
risk of falls
Personal Choice Report
September 2015
Page 48
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Walking Asikainen et
al. (2006)
128 48-63
Women
2-10 years
after onset of
menopause
One-leg
standing test
1-2 bouts of
daily brisk
walking for 15
weeks
Continuous and
fractionated
groups
No significant effect on
balance.
Two daily walking
sessions caused fewer
lower extremity
problems than
continuous walking.
Sample size
sufficient for
statistical
comparison.
Exercise dose
controlled with
supervision, HR
monitors, exercise
diaries and
pedometers.
50% of participants
reached a
maximum score in
the baseline
balance testing
therefore
decreased the
possibility to detect
a real training
effect.
Selected balance
test was not
demanding enough
for this population.
Fractionating
walking into two
daily sessions is
more feasible
than continuous
walking
Personal Choice Report
September 2015
Page 49
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Walking Clary et al.
(2006)
44 50-75
Women
Modified Clinical
Test for Sensory
Interaction on
balance,
unilateral stance
with eyes open
or eyes closed,
tandem walk
and step quick
turn tests
Walking 1 hour a
day 3 days a
week for 13
weeks
Sway velocity on firm
and foam surfaces
with eyes closed was
maintained or
decreased for walking
group (p<0.05).
Signifincant
improvements in
speed during tandem
walk test (p<0.01) and
turn time (p<0.01) and
sway (p<0.05) during
step quick turn test.
Balance was
measured by four
different methods
Supervised training
groups following a
predetermined
timeframe
Comparatively
younger age group
means good
postural stability
and balance prior to
training
Gender imbalance
Difficult to compare
MCTSI to results
from Berg Balance
Scale and
functional field tests
Walking program
results in better
improvements in
postural stability
or static balance
when compared
to the Ballates
and step aerobics
programs.
Personal Choice Report
September 2015
Page 50
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Walking Sherrington
et al. (2008)
9,6
03
Varied
between the
studies
Varied between
the studies but
centred on
measuring
strength,
balance and
endurance
Pooled estimate of the
effect of exercise
reduced rate of falling
by 17%.
Greatest relative
effects of exercise on
fall rates (RR = 0.58,
85% CI) seen in
programs that included
higher total dose of
exercise (>50 hours
over the trial period),
challenging balance
exercises and did not
include a walking
program.
Extensive review
Strong exclusion
criteria
Findings consistent
with the little that is
known about
optimal exercise
protocols from
analyses at the
level of individual
participants
Meta regression
trial level
characteristics
warrant caution.
Findings subject to
confounding
variables
Possibility that
coding of program
content does not
reflect real nature
of program
Exercise can
prevent falls in
older people.
However, the
exclusion of
walking program
shows a greater
relative effect on
falls reduction.
Personal Choice Report
September 2015
Page 51
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Yoga Brown et al.
(2007)
22 69-90 Berg Balance
Scale
One Leg
Standing Test
Activity-specific
Balance
Confidence
Scale
13 Hatha Yoga
poses 45
mins/session for
3 months
63.6% of participants
improved BBS scores
(p<0.0001)
68.2% improved OLST
scores (p=0.002)
59.1% improved ABC
scores (p=0.0065)
No significant
differences based on
age, gender or
attendance
Pilot study Short intervention
Small sample size
Lack of follow up
New preliminary
evidence to
suggest that
yoga-based
program may be
effective in
reducing risk of
falls and fall-
related injuries.
Personal Choice Report
September 2015
Page 52
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Yoga Schmid et al.
(2010)
14 >65
Endorsed fear
of falling
Illinois FoF
measure
Berg Balance
Scale
Biweekly yoga
sessions for 12
weeks
FOF decreased by 6%
Static balance
increased by 4%
(p=0.045)
Single armed pilot
study
Limited
ability/power to find
relationships
between variables
and statistically
significant
differences
Participants had
relatively
unchallenged
balance and were
not at great risk of
falling pre
intervention
Yoga is promising
intervention to
manage fear of
falling and
improve balance,
thereby reducing
risk of falls in
older adults.
Yoga Zettergen et
al. (2011)
16 79-88 Berg Balance
Scale
Fast gait speed
Biweekly, 80 min
yoga sessions
for 8 weeks
Paired t-tests revealed
improvements in BBS
scores (t=4.51,
p<0.0003) and fast gait
speed (t=2.69,
P<0.031) of yoga
participants only.
Participants in yoga
group reported feeling
steadier and less
fearful of falling.
Yoga class
designed
specifically for
community-dwelling
older adults
Small sample size
Short intervention
period
Lack of follow up
Yoga can serve
as an effective
intervention to
improve balance
in healthy older
adults.
Personal Choice Report
September 2015
Page 53
Activity Reference
Method Age N Gender Tests Other Criteria
Results Strengths Limitations Conclusion
Yoga DiBenedetto
et al. (2005)
19 62-83 Gait speed
Hip extension
ROM
90 min yoga
program, 2
times/week for 8
weeks
Improved hip
extension ROM,
improved stride length
at comfortable walking
speed and non-
significant increase in
self-selected gait
speed.
Pre and post
assessments were
performed in a gait
laboratory
Did not directly
measure falls or
risk of falling
Small sample
size/sample of
convenience
Short intervention
Yoga has positive
effects on gait
speed and hip
extension, both of
which reduce risk
of falling.