The Role of Exercise in Falls
Prevention
Dr Dawn Skelton PhD
Reader in Ageing and Health, HealthQWest,
Glasgow Caledonian University
Co-ordinator of Prevention of Falls
Network Europe, University of Manchester
Falls in the UK
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11 million people aged > 65 yrs
28,000 women aged > 90 yrs
Fractures costs £1.8 billion
1 Hip Fracture every 10 mins
– Cost £12-15K
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1 Wrist Fracture every 9 mins
– Cost £500
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Changing site of fracture >age
500 admitted to Hospital every day
33 never go home
Bandolier and Annual European
Home and Leisure Accident
Surveillance Survey (EHLASS)
Report UK 2000
Studies assessing fall risk factors per se:
[Rubenstein & Josephson 2002]
Summary of 12 major
studies of fall causes
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Accident /Environment 31%
Gait /Balance /Weakness 17%
Dizziness vertigo
13%
Drop attacks
9%
Confusion
5%
Postural hypotension
3%
Visual disorder
2%
Syncope
0.3%
Other
15%
Unknown
5%
Individual risk factors:
16 controlled studies
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Weakness
11/11
Balance deficit
9/9
Mobility limitation
9/9
Gait deficit
8/9
Visual deficit
5/9
Cognitive impairment 4/8
Impaired ADL
5/9
Postural hypotension
2/7
Time – Disease - Disuse
EVEN HEALTHY OLDER PEOPLE LOSE...
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Strength
Power
Bone density
Balance
Stamina
Flexibility
Cognitive Function
Maintenance of temperature
control
Sedentary behaviour increases the loss of performance...
International Consensus

World Health Organisation, 1996
“regular physical activity helps to preserve
independent living” and “postpone the
age associated declines in balance and
co-ordination that are major risk factors
for falls”
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Surgeon General, USA, 1997
“Sedentariness is a major public health
issue”
We are all trippers….but
when do we become fallers?
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Community Dwelling >65 years
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Compared to non-fallers, fallers have
– ⇩ 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
Fear and avoidance of activity
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Present in >50% of fallers & up to
40% non-fallers
Predicts
– decreases in physical and social
activity
– deterioration in physical
functioning
– higher risk of falling
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Particularly common in people
who cannot get up from the floor
Lessons that last a lifetime
Sensory Input  Stability
Three main sources of input
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Visual information
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Vestibular information
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Proprioceptive information
Falls Prevention Approaches
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Individual Approach (high risk patients)
– Multi-factorial (ie. Falls Clinics) Unclear evidence
– Uni-factorial (ie. Exercise) Good evidence BUT…
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Population based approach (targeting
communities)
– Emerging evidence, Relative reduction in fallrelated injuries 6 to 33%
– Most include increasing awareness and physical
activity, medication and home hazard reviews
Reviews of Exercise Evidence
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1995 – Province MA et al. - J Am Med Assoc. 273:1341-1347.
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1999 – Skelton & Dinan – Physio: Theory & Practice 15:105-120
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2000 - Gardner M et al. - Br J Sports Med. 34: 7-17
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2001 - Skelton D - Age Ageing 30;S4: 33-39
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2002 – Skelton & Beyer – Scand J Med Sports Sci 13:1-9
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2004 - Chang et al. – Brit Med J 328: 680-687
– Multifactorial interventions reduce risk (RR 0.82)
– Exercise only interventions reduce risk (RR 0.86)
Know what to avoid…
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Intervention: Brisk walking
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Control: exercise of upper
arm
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Falls risk (Brisk walking >
control)
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Beware uneven pavements!
Ebrahim et al. (1997)
Care and encouragement
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Type of Exercise
Back extension
Flexion (abd. curls)
Combined
No exercise
Sinaki 1987
Reoccurrence
of Vertebral
Fracture
16%
89%
53%
67%
‘Pitfalls’ of interventions
that don’t work
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Insufficient duration
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Insufficient intensity
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Insufficient tailoring or
specificity of training
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Insufficient progression
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Not enough time on
feet!
Balance Principles
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Changes of direction, pace and level, head position,
weight (transference)
Sustained, controlled 3D moves
Progressively challenging tasks
to improve gaze stabilisation
Obstacle courses
Floor work: balances, crawling,
rolling, shuffling in seated position
Ball games
Breakdown all moves into 'steps' or stages
Interventions that work……..
Province, 1995
Group and individual balance and strength
training >65’s
Wolf, 1996
Group Tai Chi >65’s
(NOT >70’s at risk, Wolf 2003)
Campbell, 1997
Home-based exercise >80’s (OEP)
Robertson, 2001
Home-based exercise >65’s and >80’s (OEP)
Day, 2002
Group exercise >70’s at risk
Barnett, 2003
Group exercise >65’s at risk
Lord, 2003
Group exercise >60’s retirement village
Skelton, 2005, 2008
Group Exercise >65’s frequent fallers (FaME
or PSI)
Tai Chi – prevention of
st
1
fall?
- Community Dwelling older people with mild deficits of
strength/balance, 2x/week for 15 weeks
Wolf et al. (1996)
– Cut trip and fall rate by half
- Frail older adults aged 70-97, 2 x/week
for 48 weeks
- no significant reduction in risk of falls
Wolf et al. J Am Geriat Soc 2003; 55: 1693-1701
- Community Dwelling older people aged 70+
- 3 x/week for 24 weeks
- Increased Falls Self-Efficacy and Decreased Fear of Falling
Li et al. J Gerontol B Psychol Sci Soc Sci 2005; 60:P34-40
Campbell et al, BMJ, 1997
Robertson et al, BMJ, 2001
Effective Home Exercise (OEP)
Community Dwelling >80 year old women
1 Year duration - Physiotherapist support
home-based tailored progressive strength,
balance and gait training (3x p/w)
20-30% reduction in risk
Campbell J et al., BMJ, 1997
Then - Physiotherapist led nurse training
–For over 65’s – cost effective
–For over 80’s – saves money
Robertson C et al., BMJ, 2001
Then – with Visually Impaired Older People
- Not effective unless fully compliant
Campbell J et al., BMJ, 2005
FaME – Group Exercise (PSI)
Aims to:
With evidence based activities:
• Increase balance
• Increase functional
capacity
• Increase bone / muscle
mass
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• Increase confidence
(reduce fear of falling)
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Dynamic balance training
Targeted resistance training
Targeted bone loading
Functional movements
Dynamic endurance training for
balance
Backward chaining
Functional floor activities
Adapted Tai Chi cool down
Following Frequency, Intensity, Duration and contraindication guidelines
(ACSM)
DYNAMIC BALANCE TRAINING
DYNAMIC BALANCE TRAINING
Teaching Floor Skills
Teaching transfer skills
FaME –
managing frequent fallers
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RCT - Women aged 65+ with a history of 3 or more falls in
previous year
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Exercise-only intervention – 9 months
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Group exercise – individually tailored, trained exercise instructors
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Falls risk decreased by half – RR 0.46
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Significantly less people in exercise group had died, entered a
nursing home or were in hospital after 3 years
Skelton et al. 2005
STRENGTH / POWER / ASYMMETRY
FaME
Significant isometric and isokinetic improvements in the exercise
group:
• Ankle Plantarflexion
60%
• Ankle Dorsiflexion
40%
• Ankle Inversion
25%
• Ankle Eversion
30%
• Hip Flexion
20%
• Lower Limb Power
25%
• Asymmetry reduced
15%
FaME – Bone improvements
Significant difference with time and group for L2-L4 spine and Wards Triangle (F=3.46,
p<0.05). Exercisers n=32, Controls n=14. Time between visit 1 and visit 2 = mean 10.9
(sd 2.7) months
Skelton et al. J.Aging Phys Act 2008, Abstract
Quality of Life
– adding life to years
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Improvements in ALL domains of SF36 (QoL)
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Self-reported improvements in
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Caring skills
Playing with grandchildren
Bathing instead of showering
Using public transport again
Reduced fear
Increased activity outdoors
Confidence
Fallen Angels Club
– Meet every two months in Starbucks, Oxford Street, London,
UK!
Nursing Home Residents
Individually tailored GROUP exercise as part of a multifactorial
intervention (staff training, environment modification, drug review etc)
Reduces falls - Becker et al. J Am Geriat Soc 2003; 51:306-313
Improves mobility - Jensen et al. Aging Clin Exp Res 2004; 16: 283-292
Reduces falls risk factors - Dyer et al. Age Ageing 2004; 33:596-602
Nursing Home Residents
1 to 1 training
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Whole Body Vibration vs Physical Therapy
42 residents, RCT
2 x/week for 6 weeks
Reduction in risk factors (Gait, Balance, TUG, QoL)
Bruyere O et al. Arch Phys Med Rehabil 2005:86: 303-307
• 6 months training in post-menopausal women
• Strength 15%, Hip BMD 1%
Verschueren SM et al. J Bone Miner Res 2004; 19: 352-359
Patients in Hospital
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Tai Chi + reaching + stepping + transferring chair to
chair
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1 physiotherapist to max 4 patients, 3 x p/w, 45 mins.
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173 patients, 82 yrs, sub-acute ward
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Halved the number of falls (participant days in hospital)
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Haines et al. Clin Rehab 2007; 21:742-753
My residents are too frail?
Dose response curve
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The lower the baseline level
of physical activity, the
greater the health benefit
associated with an increase
in physical activity. Exercise
can be adapted for any
medical condition
(Haskell 1994)
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There would be no falls if
there was no rehabilitation!
(Oliver, D – 2006)
Confidence in instruction &
teaching to increase
effectiveness?
Provision of Effective Group Exercise
Physiotherapist
Postural Stability Instructor
Otago Exercise Programme
Leader
Seniors Exercise Instructor
UK’s FOUR EXERCISE GROUPS
REFERRAL
FALLS REHABILITATION GROUP
‘FaME’ GROUP (PSI)
EXERCISE
CHAIR BASED
OTAGO HOME
PROGRAMME
EXERCISE GROUP
Community Exercise for the Older Person Sessions
(Tai Chi, EXTEND, YFIT etc)
Service Evaluation – PSI classes
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Average age 82 years, n=124
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Average attendance 79%
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Improved functional reach (p<0.01) & Timed up & go (p<0.05)
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Improved quality of life SF36 (p<0.05)
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Confidence in Balance (p<0.05)
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Timed Floor Rise (p<0.01)
Simey, Skelton, Dinan, Land & Irwin (BMJ letter, 2001)
“I can walk upstairs now. I haven’t been able to walk upstairs for
four years. I do my exercises every day at home. I know it’s doing
me good”
Recommendations for Exercise
interventions to reduce the risk of
falls and injuries
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Exercise works best within a multi-factorial
intervention programme
– Exercise should have components of balance, low impact
aerobic and strength
– To reduce fear, floorwork is recommended
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To be effective the exercise must be specific,
regular (2-3 p/w), progressive, and exceed 15
weeks duration for those at risk of falls and 9
months for those who are already falling regularly
www.profane.eu.org
www.helptheaged.org.uk/Health/HealthyAgeing/Falls
/_practitioners.htm
For information on Books, Videos and other
Resources on Falls Prevention including
training see
www.laterlifetraining.co.uk
“Man does not cease to play because he
grows old. Man grows old because he
ceases to play”
George Bernard Shaw