Age and Ageing 2001; 30-S4: 33–39
#
2001, British Geriatrics Society
Effects of physical activity on postural
stability
D AWN A. S KELTON
University College London, Institute of Human Performance, Royal National Orthopaedic Hospital, Stanmore HA4 7LP,
UK and Merton, Sutton and Wandsworth Health Authority, The Wilson, Cranmer Road, Mitcham CR4 4TP, UK
Fax: (q44) 20 8954 2317. Email: [email protected]
Introduction
Fall-induced injuries are increasing more rapidly
than demographic changes can account for [1]. The
potential effects of a fall include not only injury or death
but also fear of further falls (which limits activity and
makes the situation worse), depression and other
psychological sequelae [2]. The scientific evidence
regarding the role physical activity has to play in falls
management is confusing and inconsistent. Physical
activity and exercise have been identified as major
factors that influence the risk of falls and fractures
among older adults.
Physical activity describes any body movement that
substantially increases energy expenditure. It is commonly divided into occupational and leisure activity. Physical
activity can range from everyday actions (e.g. walking,
heavy housework and gardening) or leisure activities
such as swimming, dancing, cycling or sporting and
exercise opportunities provided in gyms and fitness
centres. Whereas exercise is used to describe planned
and structured activities where repetitive body movements are made to improve or maintain components of
fitness (e.g. strength training or a fitness programme
designed to improve cardiovascular risk or reduce falls).
Accumulating evidence indicates that physical activity
and structured exercise help maintain an independent life
by maintaining postural stability (balance), strength,
endurance, bone density and functional ability and, in so
doing, may prevent falls and injuries associated with falls
in older age (Figure 1). But some types and patterns of
physical activity or exercise do not seem to improve
postural stability, let alone prevent or reduce the risk of
falls. Indeed, some activities seem to increase the risk of
falls, either by increasing exposure to risky environmental conditions (slippery or uneven floors, cluttered
areas, bad pavements), acute fatigue, or unsafe practice
(Figure 1).
There have been calls for advice on prevention
and treatment initiatives in relation to falls and fallrelated injuries and for evidence of effectiveness, or
models of practice [3]. This paper reviews the scientific
evidence regarding the role that physical activity has
to play.
Low levels of physical activity and
exercise with increasing age
Physical fitness (e.g. adequate strength, power, flexibility,
balance and endurance) is especially important in old
age, in order to cope with everyday tasks and any
unforeseen demands such as hills, uneven ground, trips
etc., on the ageing body [4]. Over the past 50 years, due
to a massive increase in labour saving devices and overall
mechanization, the amount of daily activity we are
required to do has drastically decreased; the consequences of our sedentary lifestyles are now reflected
more than ever in the health of our older population.
The Allied Dunbar National Fitness Survey [5] in the
over 50’s found that 40% are sedentary and that over
25% of all 70 year old men, and a staggering 80% of all
70–75 year old women, are unable to do even simple
tasks such as walk a quarter of a mile comfortably on
their own. Activity was graded not just in taking part in
structured exercise, but other activities such as heavy
housework, heavy gardening and DIY and walking. One
third of the over 70’s climb no stairs and only 13% of
men and 11% of women aged 50q took part in sports
and exercise activities once a week or more. The most
commonly reported activity was ‘Keep Fit exercises’ for
both sexes [5].
Decreasing physical capacity takes older people
closer and closer to critical ‘thresholds’ of performance
necessary for everyday activities. In particular, decreasing
strength, balance and co-ordination appear to be key
factors in maintaining upright posture in dynamic
situations [4]. This can be illustrated by the change in
site of fracture with increasing age—wrist fractures
become more common in the 40s and are prevalent up
to the age of 65—with slowing reaction times it is often
no longer possible to get the hand out fast enough to
prevent the body landing heavily on the hip and trunk;
33
D. A. Skelton
Positive Effect on postural stability
or risk factors for falls
↑ balance
↑ functional ability
↑ mobility
↓ depression
↑ strength & power
↑ co-ordination
↑ gait
↓ fear of falling
Physical
Activity
Structured
Exercise
Negative Effect on postural
stability
↑ unsafe practice
↑ acute fatigue
↑ displacement of centre of gravity
↑ environmental risk exposure
Positive Effect on falls
• only with sufficient
- tailoring, duration
- frequency, intensity
• and with components of
- balance and Tai Chi
- strength and power
- endurance
- reducing asymmetry
- co-ordination
- functional/gait skills
- postural/transfer skills
- floor work
Negative Effect on falls
↑ unsafe practice
↑ acute fatigue
↑ displacement of centre of gravity
↑ environmental risk exposure
Figure 1. Physical activity and exercise: Effects on postural stability and falls. Bold lines represent strong evidence from RCT
trials and Epidemiology. Dotted lines represent weaker evidence, or data from a few selected trials.
hence fractures of the hip become more prevalent after
the age of 80 [6].
Postural stability, age and activity
Balance is a complex automatic integration of several
body systems. With age and inactivity these unconscious
processes may not integrate as well or as quickly as they
did when the person was younger. Maintaining balance
and preventing injurious falls can become problems that
require an ever increasing focus and fatiguing effort.
Most cross-sectional studies show that with ageing there
is a slowing in sway, gait patterns have a wider base, there
is an increased time in double leg support phase of
walking as well as a decrease in stride length, a decrease
in trunk rotation and an increase in pain and discomfort
that limits movement [ 7]. Sedentary older adults are also
known to adopt a more cautious walking style with
shorter step lengths and slower step velocities than active
older adults [8]. When required to increase walking
speed, older people tend to increase their cadence rather
than their stride length, younger people do the reverse.
Disease such as peripheral neuropathy, arthritis and
osteoporosis cause further gait adaptation. Other agerelated effects also affect balance; the sensitivity of skin
receptors (oedema, arthritis and medications), reflex
speeds or reaction time slows, co-ordination gets worse
(particularly hand/eye), poor eyesight and vestibular
dysfunction (often medication related).
One cross-sectional study shows close positive
association with the amount of physical activity reported
34
and postural stability in postmenopausal women [9].
The period of life during which physical and sporting
activities are practised seems also to be of importance
[10]. Recent periods of activity in over 60 year olds have
greater beneficial effects on postural stability than
activities performed only at an earlier age (30–40s).
People who had only taken up physical activity after
retiring had responses close to those who had always
been active but were better than those who had become
sedentary in their 30–40s or those who had never been
particularly active [10].
Falls
It appears that regular physical activity is an important
preventative measure against falls [6, 11] and against hip
fractures, with the risk of those who take regular activity
being more than halved [6, 12].
It is also common for fallers to have poor balance.
Poor balance is associated with an increased risk of falls
(Odd Ratio 2.6) and more strongly with recurrent falls
(Odd Ratio 5) in community dwelling 70 year olds [13].
This trial found no association of physical activity with
either falls or recurrent falls in a group of community
dwelling over 70 year olds [13]. Some researchers
measure physical activity by questionnaires, some by
heart rate monitors, others by diaries and it is likely that
these differences in measurement of physical activity is
one of the reasons for inconsistencies. Muscle function
is so strongly associated with physical activity it may be
hard to prove that both physical activity and postural
Physical activity and postural stability
stability have unique contributions to play separate from
their united role.
Frequent fallers have a very poor prognosis,
especially if they live alone and are prone to waiting
hours before they are found or can get attention [14].
One problem is often that people fall and despite there
only being a minor injury they are not able to get up off
the floor without help. If they cannot get up without
help then they are more likely, on 21 month follow-up, to
have died, to be hospitalized and to suffer functional
decline [15]. The role of activity in maintaining core
body temperature whilst on the floor should not be
forgotten. Some of the difficulty of rising from the floor
may be shock or injury but for many it is simply lack of
fitness. The largest call out for the London Ambulance
is for people aged over 65 who have fallen, yet 40% of
these people are not conveyed to Hospital, merely
picked up [16].
Modifiable risk factors for falls
Leading a sedentary lifestyle has been identified as a
factor for increased risk of falls in many trials [11, 17].
Fallers tend to be less active and may inadvertently cause
further atrophy of muscle around an unstable joint
through disuse [18].
It is common for fallers to have weak muscles,
Whipple showed that nursing home fallers had only
60% of the quadriceps strength of the non-fallers in
the home, and only 30% of the strength of community
dwelling non-fallers [19]. In community dwelling fallers,
however, quadriceps, hamstring, hip extensors and ankle
plantarflexors appear similar to people who do not fall,
but ankle dorsiflexion and lower limb power are weaker
[20]. In independent older people, power appears more
predictive of functional decline than strength per se
[21, 22]. Lower limb power asymmetry also presents
more frequently if a person is a faller [20]. Explosive
power is important in correcting a displacement or
movement error; to prevent a trip an individual must
have sufficient lower limb muscle power to get a
stabilizing leg out fast enough to prevent the fall or
reduce the severity of the effects of the fall. One slow
and weak leg may be enough to not lift a foot high
enough to miss a step, or to not be able to respond fast
enough if needed to stabilize the body.
One of the strong predictors of fall status is the
clinical test ‘stops walking when talking’ [23]. Multiple tasks performance becomes much harder with disuse
and fearful older people tend to avoid doing more than
one thing at once. Grabbing great grandmas (hold onto
objects as they walk) and patients with precocious parking
(sit down too early and miss the seat) are two types
of fallers seen in clinical practice [24]. Both groups
show clear signs of fear of falling which can alter their
postural stability [25] and often induce another fall
[24]. Movement errors or novel movements are known
to facilitate the acquisition of motor skills so conversely
fallers may inadvertently cause a loss of postural skills by
constraining their own movements [26].
Postural stability and physical activity
and exercise
Many of the risk factors for postural instability are purely
due to inactivity or ageing muscles and body functions
[27]. Tailored balance training and Tai Chi have been
shown to improve postural stability [28–30]. Exercise
should help in both the correction of displacement
(stronger muscles and better balance, co-ordination and
reactions all have a part to play), as well as in the
perception of displacement (by reducing oedema,
increasing range of motion of the ankle and reducing
arthritis, proprioception and sensation can be improved).
Body management and postural training will help remind
the body where it is in relation to its environment [18].
Fear of a further or more injurious fall tends to limit
exercise gains during a supervised class. One study
looked at exercise designed to reduce postural instability
in a risk-free environment—water [31]. They considered
two exercise groups, one water-based and one landbased, both of which exercised for 5 weeks. The waterbased group increased their functional reach (a risk
factor for falls) to a greater extent than the land-based
group [31]. Another way to increase confidence in taking
part in activity is the use of hip protectors, which allow
even frail elders to take part relatively safely in
movement [18].
The foremost worry for any health professional
working with unstable older people is that the person
falls whilst exercising or taking part in any activity.
Physical activity generally involves the use of large
movements that displace the body’s centre of gravity
and therefore taxes balance. Some studies suggest a
U-shaped association, in which the most inactive and the
most active persons may be at the highest risk [11, 32].
A recent trial considering the effect of brisk walking
on osteoporosis found that the cumulative risk of falling
was higher in the intervention group [33]. Qualified,
experienced, exercise practitioner supervision together
with a graded strengthening and walking programme
prior to commencement of walking outdoors may
contribute to better outcome measures. Obviously
water based exercise would take away this worry but
many older people do not swim, find many pools too
cold for comfort, or would be unhappy exercising so
scantily clad.
Falls and physical activity and
exercise—specificity
Despite the obvious role that lack of exercise has on
increasing the risk of falls, the evidence that exercise
35
D. A. Skelton
alone can reduce the risk of falls is inconsistent (for
reviews; [18, 32, 34, 35]). There are quite a number of
reasons for this inconsistency. Several trials have used
exercise of insufficient duration, intensity (overload) or
frequency necessary to effect change to the persons gait
or movement patterns. Other trials have only minimally
documented the types of exercise or activity used.
Studies which have not shown a reduction in risk of
falls, with supervised exercise, have often omitted to take
prospective fall data, relying rather on the persons
recollection and indeed, definition of a fall. Finally, many
trials failed to target their subjects and included nonfallers in short-term interventions. As exercise must be
specific to the task, if the subjects were not fallers preintervention, then one should not expect to reduce the
number of falls.
Although many exercise programmes have targeted
components of fitness aimed at improving the known
risk factors for falls, some have shown no reduction in
risk even with improvements in strength, balance or
co-ordination (for review; [18, 34, 35]). For example,
Millar considered seated balance exercise as part of
a multifactorial intervention and found a significant
reduction in prevalence of postural hypotension but
no difference in fall rates [36]. Another trial found
improvements in strength with progressive exercise but
no change in fall risk [37]. It is possible that for a
successful intervention, more than one or two musculoskeletal risk factors must be targeted at once or that
individual tuition is needed so that an individual’s risk
factors can be assessed rather than the groups.
The need for specificity was seen within a large series
of randomized, controlled trials called the FICSIT
programme [28]. The combined reduction in risk of
falls for all these interventions was 10%. However, those
trials which concentrated mainly on balance training saw
a reduction in risk of some 25%. The one intervention
that considered Tai Chi alone found that it delayed the
onset of the first or multiple falls by 47.5%, significantly
better than computerised balance training (feedback
sway training) [38].
The Atlanta FICSIT site compared Tai Chi training
with computerised balance training and with a control
group [38]. They found that postural sway was reduced
in the computerised balance training group but not in the
Tai Chi or control group. Because Tai Chi delays the onset
of the first or multiple falls in older people it was suggested that Tai Chi increases confidence by reducing fear
of falling (44%). Forrest showed that after Tai Chi training there is a counterintuitive reduction in anticipatory
postural adjustments and greater stability of standing
posture [39]. This was interpreted as a greater use of the
elasticity of the peripheral structures (involving muscles,
ligaments and tendons). The three-dimensional continuous, controlled, nature of the Tai Chi movements,
together with the change of head and eye position may
also be significant. The problem with blanket prescribing
of Tai Chi to people with postural instability is that many
36
Tai Chi classes are aimed at a younger population with
better postural stability and better strength. Also, few
practice current exercise warm-up guidelines or adapt
the moves appropriately for older people. A frail older
person will find this level of Tai Chi class too demanding
and may well be at risk of a fall during the class. Tai Chi
teachers should be trained or experienced with working
with older people and should adapt the class to progress
slower and to improve strength and balance before the
more demanding moves of Tai Chi are applied [18].
An individually tailored and supervised year-long
home-based programme of strength and balance
exercises (twice per week) and 5 minutes walking
(everyday) can also reduce the risk of a future fall in
women aged over 80 with and without a previous history
of falls [40]. The intervention was initially delivered by a
Physiotherapist with the self-directed phase being
sustained with progressively frequent telephone contact
to assist compliance. However, when the same programme was extended to over 65 year olds, although
there were improvements in strength and balance,
fall risk was not reduced [34].
The ‘belonging’ to a group allows better adherence to
exercise both in the community and following a research
trial [4]. A supervised class allows faster progression
of training, greater individual feedback, a secure environment, peer support, an opportunity for social interaction, acceptable touching and a reduction in feelings
of isolation (Figure 2). It also provides a valuable weekly
report back mechanism, reinforcement of exercise technique and intensity, all of which help to sustain adherence and effectiveness of the home exercise sessions
[18]. The psychological and health benefits of a regular
class environment should never be ignored in preference
for a seemingly more cost-effective intervention [4].
Floor coping strategies, transfer skills and keeping warm
while on the floor can be practised safely in a group
environment [18].
Physical activity and its role in fall prevention is still
an enigma, mostly due to the different methods of
measuring physical activity, the many and varied types
of physical activity and the difficulty in looking at
long-term adherence to unsupervised activity. One long
term (10 year) follow-up of regular walkers again showed
the importance of specificity, for although the health
of the walkers was better than those who were sedentary,
there was no significant reduction in the number of falls
they had compared to the group who stopped regularly
walking [41].
Conclusions
Many recent reviews have agreed that exercise is
effective in lowering falls risk in selected groups and
should form part of falls prevention programmes [4, 32,
34, 35]. Despite the inconsistent evidence there have
been guidelines published on the recommended use of
Physical activity and postural stability
Components of fitness to include:
$
$
$
$
$
But must be:
Strength/Power
Balance/Postural stability
Bone
Endurance/Gait
Flexibility
$
$
$
$
$
Need to target:
$
$
$
$
Regular
Individually tailored
Progressive
Educational
Enjoyable
And ensure:
Main fracture sites, bone loading
Functional, postural and pelvic floor muscles
Co-ordination, balance and reaction time
Body management in everyday situations
$
$
$
$
Opportunities for socialisation
Utilise touch
Specialist instruction
Tai Chi practice
Adapted from Skelton and Dinan, 1999, with permission
Figure 2. The components of a holistic exercise programme for prevention and management of falls.
(Guidelines Development Group)
Positive recommendations for exercise from Feder et al., 2000 [35].
$ Individually tailored exercise programmes administered by a qualified professional* reduce the
incidence of falls in a selected high-risk group living in the community.
$ Exercise programmes reduce the risk of falls in a selected group of older people with mild deficits
of strength and balance living in the community.
$ Tai Chi classes with individual tuition can reduce the risk of falls in older people.
$ Programmes that combine interventions (multifaceted—most that include exercise) reduce falls.
*physiotherapist, nurse trained in specific one to one balance work or an exercise instructor with seniors exercise and specific
postural stability training for the older adult qualifications
Figure 3. Guidelines for the prevention of falls in people over 65.
exercise alone and within multi-faceted interventions for
fall prevention [35] (Figure 3).
Through all the inconsistencies there remains one
clear fact—muscle function and fitness are essential to
an independent life. Physical activity must be specific to
it’s purpose. To improve health and modify certain risk
factors for falling (such as strength and balance),
moderate physical activity is appropriate. To reduce
falls the activity should include training in balance,
strength, co-ordination and reaction times but, to reduce
fractures, weight resisted exercise is necessary [3].
It must, however, be recognized that physical activity
and exercise take many forms and the selection of
activity exerts an important influence on the balance
between benefit and risk.
Some activities (often high intensity or duration) may
put some people (particularly fallers) at increased risk of
falls during the activity and so care should be taken in
advice given. There is still much research needed on the
types, amounts, variety and safety of physical activity and
structured exercise for the effective prevention of falls.
There is also a need to develop and include safe and
effective balance training equipment in the leisure and
gym environment, for preventative training and for
specific exercise referral schemes that may wish to focus
on falls prevention in older patients.
There are many barriers to physical activity for the
over 50s, including inadequate information from health
professionals [3]. However, the role of exercise in
maintaining quality of life, even if it does not reach its
intended aim of reducing falls, must not be underestimated [18]. Having confidence in balance and
movement, the fitness to be able to correct a trip or
get up from the floor unaided, and the coping strategies
for keeping warm and reaching help, are all vital to an
independent life.
The New National Service Framework for Older
People [42] acknowledges the evidence base relating to
the role of physical activity and exercise in Standard 8
‘The promotion of health and active life in older age’,
37
D. A. Skelton
Standard 3 ‘Intermediate Care’, Standard 5 ‘Stroke’ and,
particularly it’s role in postural stability in Standard 6
‘Falls’. The recent Joint American Geriatrics Society and
British Geriatrics Society Guidelines for the prevention
of falls recommend the ‘Get Up and Go’ test to check for
difficulty or unsteadiness, balance is the key assessment
in clinical practice [43].
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