CRITICALLY APPRAISED PAPER (CAP)
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): Randomized parallel
trial. British Medical Journal, 345, e4547. http://dx.doi.org/10.1136/bmj.e4547
CLINICAL BOTTOM LINE:
The rate of institutionalization due to falls has not decreased in the past 10 years, and it is
essential to develop effective strategies for fall prevention for the older population. Active
participation in strengthening and balancing activities are found to improve functional
competencies. However, less than 10% of the older population routinely engage in fall
prevention activities. The implication of incorporating balancing and strengthening activities into
daily routine practice would be helpful in fall prevention. Currently, there is no research study on
the effectiveness of such an approach in older people who are at risk of falling. Therefore, the
researchers in this study investigated the effectiveness of the Lifestyle integrated Functional
Exercise (LiFE) program for fall reduction.
The researchers conducted a three-arm randomized parallel trial, with measurement assessed at
baseline, 6 months, and 12 months. Intervention groups included home-based LiFE approach,
structured program, and sham control program. The LiFE and structured programs provided
graded balancing and strengthening exercises over 5 intervention sessions, 2 booster visits and 2
phone calls, whereas the controlled program provided 3 home visits sessions and 6 phone calls.
All interventions were provided by trained physiotherapists and occupational therapists. The
strategies of the LiFE approach focused on developing a new habitual daily routine by
integrating graded balancing and strengthening exercises into daily activities. The balance
approaches of the LiFE included static and dynamic standing balance, weight shifting, narrowing
the base for standing support, and rotating the body in different directions. The strengthening
approaches of the LiFE included bearing weight on the toes or heels, squeezing muscles, making
squads, and stepping sideways. The participants were encouraged to practice the exercises when
they could throughout the day.
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The outcome of the LiFE approach was significant, with a 31% fall reduction compared to the
controlled programs for the older adults aged 70 or older who lived at home more than 1 year.
The secondary outcome measurements between the LiFE program and control group were
significant in eight level balance hierarchy (p < .0001), five level balance hierarchy (p = .001),
Chatillom DMG250 modified dynamometer (right ankle strength p =.005, left ankle strength p <
.001), and Activities Specific Balance Confidence Scale (p = .004).
The LiFE program contributes to the awareness and idea for possible intervention of integrating
graded strengthening and balance training into daily activities, which can be practiced any time
of the day to reduce falls in the older population.
RESEARCH OBJECTIVE(S)
List study objectives.
To determine whether a lifestyle integrated approach to balance and strength training is effective
in reducing the rate of falls in older, high-risk people living at home over a year.
DESIGN TYPE AND LEVEL OF EVIDENCE:
Level I: Three arm, randomized parallel trial
SAMPLE SELECTION
How were subjects recruited and selected to participate? Please describe.
Subjects were selected to participate from the Department of Veteran’s Affairs (DVA)
databases. Invitations were sent to veterans, their spouses, or widows in the urban area of
Sydney, Australia, and the general practice databases.
Inclusion Criteria
Older adults age 70 years or older with 2 or more falls or one injurious fall in the past 12
months noted by self-report.
Exclusion Criteria
Older adults with moderate to severe cognitive problems, inability to move about
independently due to neurological condition that greatly affect their gait and mobility, and
those with no conversational English skills were excluded. Residents living in a nursing home
or hostel and any older adults with terminal illness that would make it impossible to perform
the planned exercises were excluded from participating.
SAMPLE CHARACTERISTICS
N= (Number of participants taking part in the study)
#/ (%) Male
143/ (45%)
317
#/ (%) Female
2
174/ (55%)
Ethnicity
NR
Disease/disability diagnosis
Sustained 2 or more falls or one injurious fall in the past 12
months.
INTERVENTION(S) AND CONTROL GROUPS
Add groups if necessary
Group 1
Brief description of the
intervention
The LiFE Program embedded graded balance and strengthening
exercises into habitual daily activities that the participants performed
multiple times during the day. The participant manuals were
provided as examples for individualized intensity adjustment, which
included prescribed graded balance strategies over time to integrate
into daily activities with base of support reduction, weight shifting,
directional changing, and stepping over items. In addition, the
adjustment contained prescribed graded strengthening strategies over
time to integrate into daily activities with resistive lower extremities
movement focusing on applying body weight on knees and toes,
muscle tightening, and sideways walking.
How many participants
in the group?
107
Where did the
intervention take place?
Home at metropolitan area
Who delivered?
Physiotherapists and occupational therapists
How often?
7 sessions, 2 follow-up phone calls
For how long?
6 months
Group 2
Brief description of the
intervention
Structured Program: Prescribed 7 graded exercises for balance and 6
graded for lower extremities strengthening exercises with ankle cuff
weights to be performed 3 times a week.
How many participants
in the group?
105
Where did the
intervention take place?
Home at metropolitan area
Who delivered?
Physiotherapists and occupational therapists
How often?
7 sessions, 2 follow-up phone calls
For how long?
6 months
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Group 3
Brief description of the
intervention
Control: Non-graded 12 gentle and flexibility exercises while seated,
supine, or standing while holding on support.
How many participants
in the group?
105
Where did the
intervention take place?
Home at metropolitan area
Who delivered?
Physiotherapists and occupational therapists
How often?
3 sessions, 6 follow-up phone calls
For how long?
6 months
Intervention Biases: Check yes, no, or NR and explain, if needed.
Contamination:
YES ☐
NO ☒
NR ☐
Comment: The structured and control groups were not exposed to the LiFE
program because all group participants received the interventions
individually at their homes.
Co-intervention:
YES ☒
NO ☐
NR ☐
Comment: The research study ensured that the participants did not have
involvement with other fall prevention programs.
Timing:
YES ☐
NO ☒
NR ☐
Comment:
Site:
YES ☒
NO ☐
NR ☐
Comment: Interventions did not occur in a standardized environment.
Use of different therapists to provide intervention:
Comment: The physiotherapists and occupational therapists were trained for
YES ☒
intervention deliveries.
NO ☐
NR ☐
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MEASURES AND OUTCOMES
Complete for each measure relevant to occupational therapy:
Measure 1:
Name/type of
Daily Calendar
measure used:
What outcome was Numbers of falls
measured?
Is the measure
YES ☐
NO ☐
reliable?
Is the measure
YES ☐
NO ☐
valid?
When is the
Monthly for 12 months
measure used?
Measure 2:
Name/type of
measure used:
What outcome was
measured?
Is the measure
reliable?
Is the measure
valid?
When is the
measure used?
Measure 3:
Name/type of
measure used:
What outcome was
measured?
Is the measure
reliable?
Is the measure
valid?
When is the
measure used?
Measure 4:
Name/type of
measure used:
What outcome was
measured?
NR ☒
NR ☒
Short Physical Performance Battery—Balance test (5-level scale)
Static balance
YES ☐
NO ☐
NR ☒
YES ☐
NO ☐
NR ☒
Assessment at baseline, at 6 and 12 months
Physical Performance Battery—Balance test (8-level scale)
Static balance
YES ☐
NO ☐
NR ☒
YES ☐
NO ☐
NR ☒
Assessment at baseline, at 6 and 12 months
Chatillom DMG250 modified dynamometer with removable stand
Lower limb strength with the highest of three measurements
5
Is the measure
reliable?
Is the measure
valid?
When is the
measure used?
Measure 5:
Name/type of
measure used:
What outcome was
measured?
Is the measure
reliable?
Is the measure
valid?
When is the
measure used?
YES ☐
NO ☐
NR ☒
YES ☐
NO ☐
NR ☒
Assessment at baseline, at 6 and 12 months
Activities Specific Balance Confidence (ABC) Scale
Self-efficacy in balance
YES ☐
NO ☐
NR ☒
YES ☐
NO ☐
NR ☒
Assessment at baseline, at 6 and 12 months.
Measurement Biases
Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain.
Comment:
YES ☒
NO ☐
NR ☐
Recall or memory bias. Check yes, no, or NR, and if yes, explain.
Comment: Fall history may be subjected to recall bias.
YES ☒
NO ☐
NR ☐
Others (list and explain):
RESULTS
List key findings based on study objectives
Include statistical significance where appropriate (p < .05)
Include effect size if reported
Daily Calendar:
172 falls (21 fell once, 39 fell at least twice, 1.66 falls per person) in the LiFE group in 12
months; 193 falls (24 fell once, 41 fell at least twice, 1.90 falls per person) in the structured
exercise group in 12 months; 224 falls (26 fell once, 45 fell at least twice, 2.28 falls per person)
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in the control group in 12 months. There was a significant fall reduction (95% CI 0.48-0.99)
when comparing the LiFE program with the control group. However, there was no significance
in fall reduction when comparing between the structured group and the control group (95% CI
0.81).
Five level balance hierarchy:
LiFE vs. control: p = .001, effect size = .55; structured vs. control: p = .04, effect size = .33. The
balance outcomes from the LiFE program were considered moderate to large effect sizes in
comparison to the control group, whereas the balance outcomes found moderate effect size
between the structured group and the control group.
Eight level balance hierarchy:
LiFE vs. control: p < .0001, effect size = .63; structured vs. control: p = .08, effect size = .29.
The balance outcomes from the LiFE program were considered moderate to large effect sizes in
comparison to the control group, whereas the balance outcomes found small to moderate effect
sizes between the structured group and the control group.
Chatillom DMG250 dynamometer
 LiFE vs. control (right ankle strength): p = .005, effect size = .40; structured vs. control
(right ankle strength): p = .10, effect size = .26.
 LiFE vs. control (left ankle strength): p < .001, effect size = .40; structured vs. control (left
ankle strength): p = .34, effect size = .17. Significant progress in ankle strength with medium
to large effect size was shown in comparing the LiFE program to the control group. Authors
reported no significant improvement for the right and left knee strength and hip strength.
Activities Specific Balance Confidence Scale:
LiFE vs. control: p = .004, effect size = .38; structured vs. control: p = .006, effect size = .37.
The outcomes of the balance confidence scale from the LiFE program were considered moderate
to large effect sizes in comparison to the control group, as well as between the structured group
and the control group.
The patterns for poor adherences in the first 6 months include LiFE group 7%, structured group
19%, and control group 12%. At 12 months, 64% of participants in the LiFE program, 53% of
participants in the structured program, and 53% of participants in the control program were still
exercising. The adherence in the structured group was lower than the LiFE group and the control
group.
Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR,
and if no, explain.
Comment: Authors indicated that the sample size for the study was small.
YES ☐
NO ☒
NR ☐
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Were appropriate analytic methods used? Check yes, no, or NR, and if no, explain.
YES ☒
NO ☐
NR ☐
Comment: Intention to treat analysis was used due to the frequency. Causes
of missed assessments were similar between groups, which allowed realistic
estimation of the advantage of a treatment variation.
Were statistics appropriately reported (in written or table format)? Check yes or no, and if no,
explain.
Comment:
YES ☒
NO ☐
Was the percent/number of subjects/participants who dropped out of the study reported?
YES ☒
NO ☐
Limitations:
What are the overall study limitations?
The slightly small sample size might lead to type II error. The confidence interval was close to 1
when comparing the significant fall reduction between the LiFE program and the control group,
indicating that further research study with careful interpretation on the results for the LiFE
program is recommended. The exercises for the control group were not graded and the effect of
the program among fall reduction could be disputable. The rate of falling was higher than
expected, which decreased the appropriate sample size needed for the study.
CONCLUSIONS
State the authors’ conclusions related to the research objectives.
The LiFE program showed significant fall reduction in comparison to the control group for
participants ages 70 or older at home for more than 1 year. The program produced affirmative
effects, including increased energy levels and performance in activities and improved life
participation. This intervention provides an additional option to ordinary fall prevention
programs by incorporating both balance and strengthening training into daily activities within
the participants’ own environments for optimal outcomes in fall reduction with older adults.
This work is based on the evidence-based literature review completed by Choi I Chio, OTD, OTR/L and Kitsum Li, OTD,
OTR/L, Faculty Advisor, Rocky Mountain University of Health Professions.
CAP Worksheet adapted from “Critical Review Form--Quantitative Studies.” Copyright  1998, by M. Law, D. Stewart, N.
Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission.
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