TOPIC
1O
Topics
in reducing harm from falls
9
Improving balance and
strength to prevent falls
All falls prevention guidelines recommend exercise
programmes to prevent falls in people aged 65 and
older. Does any regular physical activity reduce the
risk of falls and injuries or only particular types of
exercise programmes? Do we know the frequency
and intensity needed, and which subgroups of older
people should be targeted?
Topic 9 will address these questions, as health professionals want to offer
appropriate evidence-informed advice and referrals. The required reading
includes 1) a review of characteristics of effective falls prevention
exercise programmes and best practice recommendations and 2) advice
on communicating falls prevention messages to older people. Regular
physical activity by older people helps maintain cognitive function,
reduces cardiovascular risk, helps maintain ability to carry out activities of
daily living independently, improves mood and can improve self-esteem.
Hence, the required reading also includes 3) a factsheet on physical
activity for older people.
Exercises can improve strength,
balance, motor control and
cognition in older people
Many different risk factors contribute to falls and subsequent
injuries, but muscle weakness, poor balance and unsteady
gait underlie most falls.1 Older people with muscle
weakness, balance or gait deficits or mobility limitations are
3–5 times more likely to fall in any one year than their peers
without these functional impairments.2
Exercise is physical activity that is planned, structured,
repetitive and aimed at improvement or maintenance
of one or more components of physical fitness. Strength
training exercises increase muscle strength, core balance
and gait, even in frail older adults who are relatively weak.3
Mental skills become less efficient as we age, resulting in a
downturn in the quality of physical and mental performance.
However, strength and balance exercises have been shown
to improve executive function (cognitive processes) and
central and peripheral neurological control in older people.4
Not all types (or combination of
types) of exercises reduce falls. The
different types of exercises tested in
falls prevention trials are defined in a
taxonomy and include: gait, balance
and functional training; strength/
resistance; flexibility; 3D (eg, tai
chi); general physical activity; and
endurance.5
Which exercise programmes
prevent falls?
There is a strong evidence base for the effectiveness of certain exercise
programmes in reducing falls in older people.6, 7 The features of these
programmes differ in important ways such as the types of exercises
included, the delivery setting and the target group.
The most recent Cochrane review of falls prevention interventions in
older people living in the community included 59 randomised controlled
trials testing exercise programmes:6
• Multiple-component group exercise classes reduced falls by 29
percent (16 trials, 3622 participants). The classes were equally effective
in those selected, and not selected, for higher risk of falling.
• Multiple-component home-based exercise reduced falls by 32 percent
(seven trials, 951 participants). Three of these trials tested the Otago
Exercise Programme (OEP) in Dunedin and Auckland.8
• Tai chi classes reduced falls by 28 percent (five trials, 1563 participants).
Tai chi was more effective in the trials recruiting participants not at
high risk of falling.
Effective multiple-component
Balance retraining
programmes typically included balance
retraining and lower limb muscle
exercises are key.
strengthening exercises against resistance.6
Walking can be included when considered
safe and appropriate, but high-risk
individuals should not be prescribed brisk walking programmes.7 Walking,
on its own, does not reduce falls but does benefit cardiovascular and
overall health.
Integrating balance and strengthening exercises into everyday activities
is effective in reducing falls.9 New programmes in the pilot stage for
preventing falls include step training using videogame technology.10
The Cochrane review of falls prevention interventions in care facilities
and hospitals concluded that exercise might reduce falls by 20 percent in
people in rest home level care, but increase falls by 29 percent in facilities
providing long-term hospital level care.11
All falls prevention guidelines, for example, from the US Preventive
Services Task Force, recommend exercise to prevent falls in older
people.12 The guidelines from the American Geriatrics Society and British
Geriatrics Society Panel on Falls Prevention in Older People recommend
that all older adults at risk of falling should be offered an exercise
programme incorporating balance, gait and strength training.3
Continued over
National
Patient
Safety
Campaign
2
Falls prevention exercise programmes
reduce injuries
Encouraging older people to take
part in exercise programmes
Systematic reviews and meta-analyses have shown that exercise
programmes designed to prevent falls in older adults reduce the injuries
caused by falls by 37 percent in community-living older people (17
trials, 4305 participants),13 and reduce the risk of sustaining a fall-related
fracture by 66 percent (six trials, 810
participants).6 These programmes also
Falls prevention
reduce the rate of falls requiring medical
exercise
13
care by 43 percent.
To ensure uptake and adherence, exercise programmes should be
acceptable to older people, and this needs to be considered at the
design stage. Barriers to participation include fatalism, fear of falling,
denial and underestimation of the risk of falling, poor self-efficacy, no
previous history of exercise, poor health and functional ability, low
health expectations and the stigma associated with programmes that
target older people.24
programmes
Offering choices both in terms of type of exercise and whether
delivered as an individual or a group-based activity makes it more likely
the older person will take part.25 Many older people enjoy the social
aspects of group classes, but others dislike joining groups or find it
difficult to attend. Home-based programmes should also be offered.
The home-based OEP reduced fall-related
reduce fall-related
injuries by 35 percent (four trials, 1016
fractures and
participants),8 and also reduced the
injuries.
risk of death in the study period by 55
percent (seven trials, 1503 participants).14
This programme was more effective in
participants aged ≥80 years. Injurious falls were reduced by 46 percent
more in this age group than in those aged 65 to 79.8
Many older people do not think they
are at risk of falling, so uptake should
be promoted by emphasising the
multiple positive benefits for health
and wellbeing, including maintaining
independence.25 A personal invitation
from a health professional is important,25
for example, with a Green Prescription.
In addition, meta-analyses suggest a relatively small, but possibly
important, effect of exercise on bone density in postmenopausal
women.15 Osteoporosis Australia recommends regular weight-bearing
exercise to help maintain bone density.16
Exercising can carry risks. Falls prevention exercise programmes have
generally been shown to be safe, but participants in one trial, where
heavy ankle cuff weights were used, had back or knee pain directly
attributable to the resistance exercises.17 As a general rule, exercises
should start light, and then gradually progress in difficulty and intensity.18
Exercise programmes delivered by experienced instructors or nurses
trained and closely supervised by a senior physiotherapist have been
shown to be effective. This approach ensures safe techniques, and
optimal benefit from each exercise.
The Accident Compensation Corporation (ACC) recommends several
approaches, including:
How often and for how long?
• ‘Steady As You Go’, an Otago-based peer-led programme, which
has proved successful in maintaining measures of strength and
balance, and continuation of exercise classes26
A meta-analysis investigating the characteristics of effective falls
prevention exercise programmes concluded that:7
• ‘Upright and Able’, a six-week exercise and education intervention
run in partnership with Nelson Bays PHO. This programme aims to
support people into community-based activities and targets the
older person at risk of a fall via a ‘single point of entry’ system.
• exercises should be undertaken for a total of at least two hours per
week on an ongoing basis
• the benefits of exercise are rapidly lost when exercise is ceased
• there were larger reductions in falls as a result of programmes
involving a higher ‘dose’ of exercise (≥50 hours over a six-month
period was categorised as ‘high’ and <50 hours as ‘low’ dose)
Exercising can be broken down into shorter segments during the day,
and can be incorporated into everyday activities.
Exercise programmes provide good
value for money
Falls prevention exercise programmes can reduce total health care costs,
particularly when targeted to older people at high risk of falling.19
We have a greater likelihood of success in meeting the challenges
posed by an ageing population when organisations collaborate in an
integrated, system-wide approach.
Providing the OEP to women ≥80 years reduced health care costs for
treating fall-related injuries and returned an estimated $1.85 for each $1
spent (185 percent return on investment).20 Tai chi returned an estimated
$1.60 for each $1 spent (160 percent return).21
Effective programmes can reduce fall-related hospital admissions in
community-living older people by 0.5–10.0 percent.22
A trial of the OEP in Auckland showed cost savings resulting from fewer
fall-related hospital admissions in participants aged ≥80 years.23
The US Centers for Disease Control and Prevention (CDC) has recently
echoed New Zealand’s earlier initiative18 by national roll-out of the OEP
and tai chi to reduce falls in targeted groups.
REFERENCES
• time spent exercising can be a mixture of group classes and homebased exercise.
Don’t mention the
f-word! Emphasise
that exercise
programmes have
many positive benefits.
1. Campbell AJ, Borrie MJ, Spears GF. 1989. Risk factors for falls in a community-based
prospective study of people 70 years and older. Journal of Gerontology 44(4): M112–7.
2. Rubenstein LZ. 2006. Falls in older people: epidemiology, risk factors and strategies for
prevention. Age and Ageing 35 Suppl 2: ii37–ii41.
3. Panel on Prevention of Falls in Older Persons, American Geriatrics Society, 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 the American Geriatrics Society 59(1): 148–57.
4. Sherrington C, Henschke N. 2013. Why does exercise reduce falls in older people?
Unrecognised contributions to motor control and cognition? British Journal of Sports
Medicine 47(12): 730–1.
5. Lamb SE, Becker C, Gillespie LD et al. 2011. Reporting of complex interventions in
clinical trials: development of a taxonomy to classify and describe fall-prevention
interventions. Trials 12: 125.
6. Gillespie LD, Robertson MC, Gillespie WJ et al. 2012. Interventions for preventing falls
in older people living in the community. Cochrane Database of Systematic Reviews (9):
CD007146.
7. Sherrington C, Tiedemann A, Fairhall N et al. 2011. Exercise to prevent falls in older
adults: an updated meta-analysis and best practice recommendations. New South
Wales Public Health Bulletin 22: 78–83.
8. Robertson MC, Campbell AJ, Gardner MM et al. 2002. Preventing injuries in older
people by preventing falls: a meta-analysis of individual-level data. Journal of the
American Geriatrics Society 50(5): 905–11.
9. Clemson L, Fiatarone Singh MA, Bundy A et al. 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. BMJ 345: e4547.
10. Schoene D, Lord SR, Delbaere K et al. 2013. A randomized controlled pilot study of
home-based step training in older people using videogame technology. PLoS One
8(3): e57734.
11. Cameron ID, Gillespie LD, Robertson MC et al. 2012. Interventions for preventing
falls in older people in care facilities and hospitals. Cochrane Database of Systematic
Reviews (12): CD005465.
12. Moyer VA, on behalf of the U.S. Preventive Services Task Force. 2012. Prevention
of falls in community-dwelling older adults: U.S. Preventive Services Task Force
recommendation statement. Annals of Internal Medicine 157(3): 197–204.
13. El-Khoury F, Cassou B, Charles M-A et al. 2013. The effect of fall prevention exercise
programmes on fall induced injuries in community dwelling older adults: systematic
review and meta-analysis of randomised controlled trials. BMJ 347: f6234.
14. Thomas S, Mackintosh S, Halbert J. 2010. Does the ‘Otago exercise programme’
reduce mortality and falls in older adults?: a systematic review and meta-analysis. Age
and Ageing 39: 681–7.
Acting on the evidence: key
messages?
There is strong evidence that certain exercise
programmes can reduce falls and even the most
serious injuries caused by falls, such as fractures, in
community-living older people.
Effective programmes, when implemented, reduce
health system costs by reducing fall-related hospital
admissions in community-living older people by up
to 10 percent, and provide a return on investment
of 160–185 percent.
Targeting falls prevention exercise programmes
• Generally falls prevention exercise programmes are equally effective
in the general community and those at higher risk for falls. However,
these programmes are likely to give better value for money in people
at higher risk, eg, those who report falling in the previous year.
• The message for targeting tai chi is that it seems more effective in
reducing falls in those not at high risk of falling.
• Falls prevention exercise programmes may reduce falls in agerelated residential care residents receiving rest home level care. But
in trials that included residents receiving hospital level care, exercise
programmes resulted in increased falls. Input from an appropriate
health professional is recommended.
Characteristics of effective programmes
• Falls prevention exercise programmes can be delivered in a group or
home-based setting.
• To prevent falls, the exercises must provide a moderate or high
challenge to balance, and lower body strength training exercises are
generally included.
• The exercise programme should be of sufficient ‘dose’ – at least
2 hours per week is recommended. This can include a mixture of
group and home-based exercise.
• Ongoing exercise is needed because the benefits are lost when
exercising stops.
• Walking offers general health benefits but individuals at high risk of
falling should not be prescribed brisk walking programmes.
Encouraging participation
REFERENCES continued
• The individual should receive a personal invitation from a health
professional and be offered a choice of programme types and
settings.
• As many older people reject the idea they are at risk of falling,
promotion of exercise programmes should emphasise the positive
benefits for health, wellbeing and independence.
15. Howe TE, Shea B, Dawson LJ et al. 2011. Exercise for preventing and treating
osteoporosis in postmenopausal women. Cochrane Database of Systematic Reviews
(7): CD000333.
16. Ebeling PR, Daly RM, Kerr DA et al. 2013. Building healthy bones throughout life: an
evidence-informed strategy to prevent osteoporosis in Australia. Medical Journal of
Australia Open 2(Suppl 1): 1.
17. Latham NK, Anderson CS, Lee A et al. 2003. A randomized, controlled trial of
quadriceps resistance exercise and vitamin D in frail older people: the Frailty
Interventions Trial in Elderly Subjects (FITNESS). Journal of the American Geriatrics
Society 51(3): 291–9.
18. Campbell AJ, Robertson MC. 2010. Comprehensive approach to fall prevention on a
national level: New Zealand. Clinics in Geriatric Medicine 26(4): 719–31.
19. Davis JC, Robertson MC, Ashe MC et al. 2010. Does a home-based strength and
balance programme in people aged ≥80 years provide the best value for money
to prevent falls? A systematic review of economic analyses of falls prevention
interventions. British Journal of Sports Medicine 44: 80–9.
20. Hektoen LF, Aas E, Luras H. 2009. Cost-effectiveness in fall prevention for older
women. Scandinavian Journal of Public Health 37(6): 584–9.
21. Carande-Kulis VG, Stevens J, Beattie BL et al. 2010. The business case for interventions
to prevent fall injuries in older adults. Injury Prevention 16(Suppl 1): A249.
22. Robertson MC, Campbell AJ. December 2012. Falling costs: the case for investment.
Dunedin, New Zealand: University of Otago.
23. Robertson MC, Devlin N, Gardner MM et al. 2001. Effectiveness and economic
evaluation of a nurse delivered home exercise programme to prevent falls. 1:
Randomised controlled trial. BMJ 322(7288): 697–701.
24. Bunn F, Dickinson A, Barnett-Page E et al. 2008. A systematic review of older
people’s perceptions of facilitators and barriers to participation in falls-prevention
interventions. Ageing and Society 28: 449–72.
25. Yardley L, Bishop FL, Beyer N et al. 2006. Older people’s views of falls-prevention
interventions in six European countries. Gerontologist 46(5): 650–60.
26. Waters DL, Hale LA, Robertson L et al. 2011. Evaluation of a peer-led falls prevention
program for older adults. Archives of Physical Medicine and Rehabilitation 92(10):
1581–6.
6O
MINUTES
of professional development
3
Undertaking this learning activity is equivalent to
60 minutes of professional development and can be
added to the personal professional record you keep for
competence framework requirements.
Learning objectives
Reading and reflecting on TOPIC 9 and the materials in this teaching/
learning package will enable learners to:
1 Outline best practice recommendations for exercise to prevent falls
in older people.
2 Explain the rationale for muscle strengthening and balance retraining
in preventing falls in older people.
3 Base advice and referrals for balance and strength exercises on
current evidence.
4 Explore positive approaches to promoting balance and strength
exercises with patients/residents/clients and their families.
Teaching/Learning package
Gather up the resources you’ll need by using the hyperlinks in the text, or
download or print them as separate items.
REQUIRED READING
These readings will help you form evidence-informed perspectives
about exercise to prevent falls in older people:
1 This review investigated the characteristics of effective falls
prevention exercise programmes and makes best practice
recommendations.
2 Don’t mention the f-word! Advice on communicating falls
prevention messages to older people is based on a study
encouraging positive attitudes to falls prevention in later life.
3 Ministry of Health factsheet on physical activity for older people.
CONSUMER RESOURCES
10 myths and facts about falls for consumers.
Balance and strength exercises you can do at home.
Ministry of Health factsheet on physical activity for older people.
The US CDC website also lists positive benefits of physical activity.
International Osteoporosis Foundation exercise recommendations.
HEALTHCARE PROVIDER RESOURCES
Audiovisual: Staying safe on your feet at home (12 minutes 26
seconds) describes a coordinated falls prevention programme in
Christchurch incorporating a home exercise programme.
Instructor’s manual for the Otago Exercise Programme (includes the
exercise sheets to photocopy for clients).
Falling costs: the case for investment investigated value for money of
exercise programmes to prevent falls in older people in New Zealand.
Ministry of Health Guidelines on physical activity for older people.
ACC-recommended programmes ‘Steady As You Go’ and
‘Upright and Able’.
For information on tai chi for older people see Tai chi for falls prevention
and Tai Chi: Moving for Better Balance.
+3O MINUTES RECOMMENDED VIEWING
These three audiovisuals show falls prevention exercise programmes as
part of an holistic approach to falls prevention. Viewing them enables
learners to relate evidence and best practice to real life initiatives.
• Staying on your feet in the community (13 minutes 19 seconds)
describes the peer-led falls prevention group exercise programme
‘Steady As You Go’ in Otago.
• Staying safe on your feet at home (12 minutes 26 seconds)
describes a coordinated falls prevention programme in Canterbury
incorporating a home exercise programme.
• Preventing falls in an aged residential care facility (7 minutes 52
seconds) looks at how one aged residential care facility is working
with residents and their families to prevent falls.
December 2013 v1
4
1O Questions
TOPIC
9
Professional development activity
Improving balance and
strength to prevent falls
Answer these questions to check that you have retained the knowledge reviewed in this topic and reading (Select one option)
The researchers report in the required reading Exercise to prevent falls in older adults (Table 2) that exercise programmes with balance
training, no walking training and a higher exercise dose can prevent falls by up to:
18% 28% 38% 48%
2
This reading’s first best practice recommendation is that exercises must provide a moderate or high challenge to balance to be effective
in preventing falls. Exercises aimed at achieving this do not include:
Extending the base of support while standing. Movement of the centre of gravity while standing.
Reducing the need to use the arms for support while standing.
3
Mr Brown who is 72 years old, says his legs are “not as good as they were”. He is wondering what physical activity and exercise he should
add to his weekly round of golf to ‘future-proof’ himself. How would you approach a conversation with Mr Brown?
Advise him to take it easy – golf once a week is enough physical activity and there is no benefit in adding specific exercises.
Discuss the recommendations in this factsheet with him, and suggest participation in a tai chi or group exercise class.
4
Mrs Jones who is 79 years old and living independently, recently lost her balance and had a fall while she was out with friends. She
suffered bruising and she is afraid of falling again. She is wondering if physical activity or exercises could help prevent another fall. What
would your evidence-informed suggestion be?
Stay at home and move about the house as little as possible to reduce the risk of falls.
Regularly attend a falls prevention exercise class at the local community centre.
Go for a very brisk walk for two hours every day for the next three weeks.
5
Mrs Smith who is 83 was discharged from hospital after fracturing her wrist in a fall. She lives with her daughter and is motivated ‘not to
be a burden’. The community physiotherapist has visited to teach her a set of exercises she can do at home. Which option is better for
Mrs Smith if she is to reduce the risk of further falls?
Around 30 minutes once each week for two months, then discontinue the exercises.
Around 30 minutes a day on three days each week for six months, and continue the exercises.
answer
1
Assess the processes used for assessing strength and balance impairments in older people in your setting
What is the process in your care setting for assessment as to whether older patients/residents/clients might have problems with their
balance, gait or lower body strength?
What would need to change (if anything) to put in place a methodical and consistent approach to assessing all older people for balance
and lower body strength?
7
assess
6
Describe three specific things you already do (or could do) to promote participation in safe falls prevention exercise programmes for
your patients/residents/clients?
Outline three learnings or insights and how you will apply them in your practice
I will apply it in practice by….
9 My second learning/insight is…
I will apply it in practice by….
10 My third learning/insight is…
I will apply it in practice by….
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8 My first learning/insight is…