Eleftheria Antoniadou MD FEBPMR PhDc

Consultant

Rehabilitation ClinicPatras University Hospital

The benefits of exercise in the prevention of falls

No disclosures

Presentations Aims

• Review the problem of falls

• Define risk factors for a fall

• Analyze the various types of exercise and their impact on falls prevention

• Give some recommendation for the implementation of exercise programs

Do we age the same way?

Colombian Emilia Garcia de Fontan, 90, battles to keep up with 86-year old Gwen Gleeson from Australia in the finals of the 100m dash in the women's 85-89 and 90-94 age groups. Gleeson crossed the line 6th in her age group in 26.01 seconds, with Garcia de Fontan coming closely behind at 26.06 seconds

Definitions

• Falls are commonly defined as “inadvertently coming to rest on the ground, floor or other lower level, excluding intentional change in position to rest in furniture, wall or other object”

• Physical activity is defined as any bodily movement produced by skeletal muscles that requires energy expenditure

• Exercise is physical activity that is planned, structured, and repetitive for the purpose of conditioning any part of the body. Exercise is used to improve health, maintain fitness and is important as a means of physical rehabilitation.

• WHO W00-W19 in ICD-10,

Falls are a major health problem among older adults WHY????• 1 out of 3 people aged 65 or more living in the

community falls at least once a year• 1 out of 2 over 80 years• Females falls more but males more serious

consequences • Falls are the number one cause of mortality for elders

regarding trauma• Falls are one of the major causes of hospitalization

and lost of functional autonomy in the aging population

• Falls ore the number one risk factor to another fall

The problem

It costs!!

• Cost in Greece 850m euros

• Cost in the USA In 2015, costs for falls to Medicare alone totaled over $31 billion

• Burns EB, Stevens JA, Lee RL. The direct costs of fatal and non-fatal falls among older adults—United States. J Safety Res 2016:58.

• MARTINSON, B., A. CRAIN, N. PRONK, P. O’CONNOR, and M. MACIOSEK. Changes in physical activity and short-term changes in health care charges: a prospective cohort study of older adults.Prev. Med. 37:319–326, 2003

Risk Factors

There are over 400 risk factors associated with falling, and the risk of falling appears to increase with the number of risk factors. A multifactorial falls risk assessment allows interventions to be targeted at a person's specific risk factors to help prevent future falls

Risk Factors

• Biological risk factors

– Muscle weakness or balance problems

– Medication side effects and/or

interactions

– Chronic health conditions

– Vision changes and vision loss

– Loss of sensation in feet

-Low vit D3 levels

• Behavioral risk factors

– Inactivity– Risky behaviors such as standing on a

chair in place of a step stool

– Alcohol use

• Environmental risk factors

– Clutter and tripping hazards

– Poor lighting

– Lack of stair railings

– Lack of grab bars inside and outside

the tub or shower

– Poorly designed public spaces

Compared to non-fallers, fallers have

Community Dwelling >65 years

⇩ quadriceps and hamstring strength (NS)

⇩ ankle plantarflexion, dorsiflexion, inversion and eversion strength

⇩ lower limb explosive power

⇧ asymmetry between limbs in power and strength

• Skelton, Kennedy, Rutherford Age Ageing 2002

Type of interventions

➢Intervention strategies have consisted of single exercise (e.g., resistance exercise, walking, tai chi) or multicomponent exercise programs (e.g., aerobic endurance, flexibility, strength, and balance training).

➢Some interventions have adopted a general approach, while others have included exercises that specifically target balance and gait impairments and other physical factors known to be associated with heightened fall risk, such as muscle weakness or reduced flexibility

➢In addition to the different types of exercise, the methods of delivery (i.e., group-based versus one-to-one) and intervention setting (i.e., community, home, nursing home) have also differed across studies.

➢ Finally, the type of provider (e.g., physical or occupational therapists, nurses, physical activity instructors) responsible for designing and/or implementing the exercise intervention also has varied across studies.

Barnett A, Smith B, Lord SR, Williams M, Baumand A. Community-based group exercise improves balance and reduces falls in at-risk older people: A randomized controlled trial. Age Ageing 2003; 32: 407-14.Buchner DM, Cress ME, de Lateur BJ, Esselman PC, Margherita AJ, Price R, Wagner EH. The effect of strength and endurance training on gait, balance, fall risk, and health services use in community-living older adults. J Gerontol A Biol Sci MedSci 1997; 52A(4): M218-24.17Lord SR, Ward JA, Williams P, Strudwick M. The effect of a 12-month exercise trial on balance, strength, and falls in older women: A randomized controlled trial. J Am Geriatr Soc 1995; 43:1198-1206.Lord SR, Castell S, Corcoran J, Dayhew J, Matters B, Shan A, Williams P. The effect of group exercise on physical functioning and falls in frail older people living in retirement villages: A randomized, controlled trial. J Am Geriatr Soc 2003; 51: 1685-1692.Province M, Hadley EC, Hornbrook MC. The effects of exercise on falls in elderly patients: A preplanned meta-analysis of the FICSIT trials. JAMA 1995; 273:1341-7.Rubenstein LZ, Josephson KR, Trueblood PR, Loy S, Harker JO, Pietruszka FM,

• Intervention trials have found that the effects of exercise as a single falls prevention intervention are comparable to those from multifaceted interventions

• Therefore, widespread implementation of exercise as a single intervention seems to be the best approach to falls prevention at a population level

• Both home-based and group-based programs have been shown to prevent falls

• The availability of home-based programs is also important as many older people are reluctant to or unable to attend group exercise classes

• For the 80 years and older the home based programs with a health instructor are cost effective and neutral for younger

Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2009; CD007146.

Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JC. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc 2008; 56(12): 2234–43. doi:10.1111/j.1532-5415.2008.02014.x Lord SR, Sherrington C, Menz HB, Close JCT.

Falls in older people: risk factors and strategies for prevention. 2nd ed. Cambridge: Cambridge University Press; 2006.

Campbell AJ, Robertson MC. Rethinking individual and community fall prevention strategies: a meta-regression comparing single and multifactorial interventions. Age Ageing 2007;

Barnett A, Smith B, Lord SR, Williams M, Baumand A. Community-based group exercise improves balance and reduces falls in at-risk older people: a randomised controlled trial. Age Ageing 2003; 32(4): 407–14. doi:10.1093/ageing/32.4.407

Skelton D, Dinan S, Campbell M, Rutherford O. Tailored group exercise (Falls Management Exercise – FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age Ageing 2005; 34(6): 636–9. doi:10.1093/ageing/afi174

Yardley L, Bishop FL, Beyer N, Hauer K, Kempen GI, PiotZiegler C et al. Older people’s views of falls-prevention interventions in six European countries. Gerontologist 2006; 46(5): 650–60.

The balance system also includes the limbic system and the frontal cortex, which allows for learning complex experience-based postural and motorresponses. These higher centers are important for development and adaptivepurposes but also contribute to maladaptive behaviors, such as anxiety, avoidance,and phobia . Konrad HR, Girardi M, Helfert R. Balance and aging.

Laryngoscope 1999;109:1454 –60

Vestibular impairmentsHair cell loss occurs at a rate of approximately 3% per decade from the age of 40Sensitivity of the semicircular canals (high frequency sounds)Sensory impairmentsVisual impairmentsvisual acuity,

visual field, depth perception, Contrast sensitivity, sensitivity to glare,dark adaptationMusculoskeletal and neuromuscular impairmentsPostural response latencies are increased in the healthy elderlySarcopenia

Cardiovascular impairmentsReduced response to sympathetic stimuliImpaired baroreflex function Gait changesGait patterns in the elderly may exchange kinetic efficiency for increased postural stabilityas seen by the slowing of the gait cycle with prolonged stance and double support phasesMedicationsDiseases

Matsumura, B. A., & Ambrose, A. F. (2006). Balance in the Elderly. Clinics in Geriatric Medicine, 22(2), 395-412. doi:10.1016/j.cger.2005.12.007

Best practice recommendations

Recommendation 1

• Exercises should aim to challenge balance in three ways:

1. Reducing the base of support

2. Movement of the center of gravity

3. Reducing the need for upper limb support with exercises in standing

Recommendation 2.

Exercise must be of a sufficient dose to have an effect minimum 50 hours

Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicin and the American Heart Association. Med Sci Sports Exerc 2007; 39(8): 1435–45. doi:10.1249/mss.0b013e3180616aa2

Best practice recommendations

Recommendation 3.

Ongoing exercise is necessaryRecommendation 4.

Falls prevention exercise should be targeted at the general community as well as those at high risk for falls

Recommendation 5. Falls prevention exercise may be undertaken in a group or home-based setting

Recommendation 6.

Walking training may be included in addition to balance training but high risk individuals should not be prescribed brisk walking programsRecommendation 7.

Strength training may be included in addition to balance training

• Further trials are required in residential aged care to clarify the effect of exercise but we suggest that, at this stage, the following recommendations also apply to people in residential aged care.

• The recommendations also apply to people with cognitive impairment

While there is evidence that high-challenging balance training performed for at least 3 h per week may be most effective for falls prevention in community-dwelling older adults, such training has been shown to have no effect on bone.

Studies showing a larger annual (1.0–1.5%) decrement in strength when compared to cross-sectional observations ✓ A reduction in muscle fiber quality in fibers expressing type I or IIA myosin heavy chain✓ A greater instantaneous stiffness per force unit was measured in fibers from older men✓ This sub-clinical inflammation appears amenable to rehabilitation since it is partially reversed

with exercise training.✓ The concentration of myosin, the most important motor protein, has been shown to be

reduced in fibers from old subjects expressing type I or IIA further reduction with immobilization

Balance Principles

• Changes of direction, pace and level, head position, weight (transference)

• Sustained, controlled 3D moves

• Progressively challenging tasks to improve gaze stabilization

• Obstacle courses

• Floor work: balances, crawling, rolling, shuffling in seated position

• Ball games

• Breakdown all moves into 'steps' or stages

Evidence Based Programs

• A Matter of Balance

• FallsTalk

• FallScape

• The Otago Exercise Program

• FaME

• Stay Active and Independent for Life (SAIL)

• Stepping On

• Tai Chi for Arthritis

• Tai Ji Quan: Moving for Better Balance

• SIEL BLEU

Dancing has been proposed as a beneficial type of physical exercise (Keogh, Kilding, Pidgeon,

Ashley, & Gillis, 2009), as it allows variability in its performance, there is a

possibility to do it in multiple scenarios, it does not imply a big cost and it does not lead to boredom due to its various styles, steps and music (Lima and

Vieira, 2007).There are studies that indicate the positive effects of dancing such as the improvement of balance and the reduction of falls in elderly people (Alpert et al., 2009; Jeon

et al., 2005), the beneficial effects on cardiovascular parameters in

sedentary subjects and the improvement of agility, flexibility (Hopkins, Murrah,

Hoeger, & Rhodes,1990; Kim, June, & Song, 2003), night rest (Krampe, Miller, Echebiri, Rantz,

& Skubic, 2014) and depression (Murrock & Graor, 2013).Likewise, aerobic dancing can

influence on flexibility and strength avoiding falls (Shigematsu et al., 2002).

Considerations

• Gender specific exercises

• Compliance

• Follow-up

A quote from a Greek man

“You should be very careful about the way you would

approach old men and tell them that they might need

to participate in this…. Not everybody accepts his age

and his state”Gender perspectives on views and preferences of older people on exercise to prevent falls: a systematic mixed studies reviewMarlene SandlundEmail authorView ORCID ID profile, Dawn A. Skelton, Petra Pohl, Christina Ahlgren, Anita Melander-Wikman and Lillemor Lundin-Olsson

Summarizing take home message

• Exercises reduce falls in the elders, number of fallers, number of falls

• They must challenge balance in moderate to high intensity

• More than 50 h

• There are organized programs

• Do strength or power training