Physical Activity Guidelines Advisory Committee Report
Part G. Section 6: Functional Health
Table G6.A3. Summary Table of Studies Investigating Whether Regular
Physical Activity Reduces Rates of Falls and Fall-Related Injuries in Older
Adults Who Are at Increased Risk
Article, Study Aims, Sample, Number in Study,
Duration |
Intervention |
Functional Outcomes |
Other Effects |
Comments |
Wolf et al., 1996 (1)
- To evaluate the effects of tai chi and computerized balance
training on specified indicators of frailty and the occurrence of falls
- Men and women aged >70 years, living independently in the
community
- n=200; all included in falls analysis
- From 7 to 20 months
|
- Intervention group: 1 group tai chi 45-minute classes 2/week
for 15 weeks; also instructed to practice tai chi 2/day for 15 minutes
- Intervention group 2: one on one computerized balance training
1 day a week for 15 weeks
- Control group: 1-hour discussion of topics of interest to
older people once a week for 15 weeks
|
Tai chi (n=72) reduced risk of falls by 47.5% compared with
remainder (n=64 balance training, n=64 control group) (adjusted relative hazard
ratio 0.525; 95% CI, 0.321 to 0.860 |
At 4 months:
- Grip strength declined in all groups (P=0.025)
- People in tai chi group were less afraid of falling than
control group (P=0.046)
|
Authors considered tai chi warranted further investigation as an
exercise treatment to improve the health of older people. |
Buchner et al., 1997 (2)
- To determine the effect of strength and endurance training on
gait, balance, physical health status, falls risk, and use of health
services
- Men and women aged 68-85 years, with at least mild deficits in
strength and balance
n=105; 100 (95%) included in falls analysis
- Up to 25 months (median, 18 months)
|
- Intervention group: Center-based, supervised 1-hour sessions
3/week for 24-26 weeks, then unsupervised:
- Intervention group 1: Strength training using weight
machines
- Intervention group 2: Endurance training using stationary
bicycles
- Intervention group 3: Combination of strength + endurance
training
- Control group: Instructed to maintain usual activity
|
- Exercise (3 groups combined) increased time to first fall
compared with control group (relative hazard 0.53; 95% CI, 0.30 to 0.91)
- Exercise groups had a lower fall rate (relative risk
0.61; 95% CI, 0.39 to 0.93)
|
- At 6 months: Improvement in hip and knee strength in
strength-training group (knee strength only in combination training group)
- No effect of exercise on measures of gait, balance, or
physical health status
|
- Evidence for exercise other than balance to lower falls risk in
older people
- Evidence for lack of improvement in gait and balance with
short-term strength and endurance training in people with minor deficits in
gait and balance
|
Campbell et al., 1997 (3)
- To determine the effectiveness of an individually tailored
home exercise program in preventing falls and injuries in elderly women
- Women aged >80 years, enrolled through general
practices
- n=233; all included in falls analysis; 213 (91%) completed
trial
- 1 year
|
- Intervention group: Muscle strengthening and balance retraining
exercises (>3/week, 30 minutes), plus walking plan (>2/week,
30 minutes), individually prescribed and progressed over 4 home
visits by a physiotherapist then monthly telephone contact for 1 year (Otago
Exercise Programme)
- Control group: Equivalent number of social visits by nurse,
and usual care
|
- Relative hazard for first 4 falls for exercise group 0.68; 95%
CI, 0.52 to 0.90
- Relative hazard for a fall resulting in moderate or severe
injury 0.61; 95% CI, 0.39 to 0.97
|
- At 6 months: Balance score and chair stand test improved in
exercise group
- At 1 year: Exercise group maintained physical activity level
and falls self-efficacy score (self-confidence for daily activities without
falling)
|
- Targeted high-risk group for falling
- Program was most effective in the prevention of recurrent
falls
- Designed for wider implementation
|
Campbell et al., 1999 (4)
- To determine the effectiveness of gradual withdrawal of
psychotropic medication and a home-based exercise program in reducing
falls
- Men and women aged >65 years and currently taking
psychotropic medication
- n=93; all included in falls analysis, 72 (77%) completed
trial
- 44 weeks
|
2 x 2 factorial design:
- Intervention group 1: Psychotropic medication withdrawal,
active ingredient gradually withdrawn over 14-week period
- Intervention group 2: Exercise program (Otago Exercise
Programme) for 44 weeks.
- Control group for exercise program: No active intervention
|
- No evidence that exercise program reduced the risk of
falling
- Relative hazard for falling in medication withdrawal group
compared with original medication group 0.34; 95% CI, 0.16 to 0.74
|
- At 6-months: Exercise group improved in tests of balance and
strength: functional reach (P<0.015), knee extensor strength
(P<0.004), chair stand test (P<0.010)
- Exercise group improved in SF-36 mental component score
|
Small sample size and high dropout rate |
Robertson et al., 2001 (5)
- To assess the effectiveness of trained district nurse
individually prescribing a home exercise program to reduce falls and
injuries
- Men and women aged >75 years, recruited through general
practices
- n=240; all included in falls analysis, 211 (88%) completed
trial
- 1 year
|
- Intervention group: Muscle strengthening and balance retraining
exercises, walking plan (Otago Exercise Programme) individually prescribed and
progressed over 5 home visits and monthly telephone contact for 1 year by
trained district nurse supervised by a physiotherapist
- Control group: No active intervention
|
- Number of falls reduced in exercise group by 46% (incidence
rate ratio 0.54; 95% CI, 0.32 to 0.90)
- Fewer in exercise group had serious injury from a fall
(P <0.033)
|
- Exercise group had improved in 4‑test balance scale score
(difference 0.3, 95% CI, 0.0 to 0.5)
- Higher proportion in exercise group had improved in chair
stand and one foot stand tests
|
- This home exercise program is effective in reducing falls and
injuries when delivered by trained nurse in usual health care service
setting
- Program now tested in 4 controlled trials, total 1,016
participants
- Program manual available for health professionals
|
Barnett et al., 2003 (6)
- To determine whether a weekly group exercise program plus home
exercises improves physical functioning or health status and prevents falls in
at-risk community-living older people
- Men and women aged >65 years, >1 risk factor on
standardized assessment by general practitioner or
- hospital‑based physiotherapist
- N=163; 150 (92%) completing the trial included in falls
analysis
- 1 year
|
- Intervention group: Supervised group exercise program (mean 9
per group) for 1 hour/week for 1 year (warm up then functional balance,
coordination, and strengthening exercises, fast walking, cool down, all to
music) with ancillary home exercises (based on class content) plus information
on strategies for avoiding falls
- Control group: Provided with written falls prevention
materials only
|
- Number of falls reduced by 40% (IRR 0.60; 95% CI, 0.36 to
0.99)
- Trend for lower rate of falls injuries (IRR 0.66; 95% CI, 0.38
to 1.15)
|
- At 6 months: Exercise group performed better in tests of
postural sway and coordinated stability
- No difference in measures of strength, reaction time, walking
speed, and fear of falling or on SF‑36 and physical activity scale for
the elderly scores
|
- Although relatively low intensity, program targeted group with
reduced physical functioning
- “Considerable emphasis” on balance exercises
|
Lord et al., 2003 (7)
- To determine whether a 12-month program of group exercise
could improve physical functioning and reduce falls in frail older people
- Men and women aged 62-95 years, resident in self and
intermediate care retirement villages
- n=551; 508 (92%) completed study and included in falls
analysis
- 1 year
|
- Intervention group: Exercise classes (warm up, aerobic,
strengthening, balance, hand/eye and foot/eye coordination, cool down) 1 hour
2 days a week for 12 months
- Control group: n=90, flexibility and relaxation program 1 hour
2 days a week for 12 months; n=181, no active intervention
|
Number of falls 22% lower in intervention group (adjusted
incidence rate ratio 0.78; 95% CI, 0.62 to 0.99) |
After 6 months:
- Choice stepping reaction time (P <0.01), 6-minute
walking distance tests (P <0.05) performed better by intervention group
|
- Exercise classes individualized to functional capabilities of
participant
- Exercises designed to address known major risk factors for
falls and to improve ability to perform activities of daily living
|
Wolf et al., 2003 (8)
- To determine whether an intense tai chi program could reduce
the risk of falls more than a wellness education program in older adults
transitioning to frailty
- Men and women aged
≥70 years, from congregate living
facilities, use of 10 attributes to define not “vigorous” and
not “frail”
- n=311; 286 (92%) included in analysis
- 48 weeks
|
- Intervention group: “Intense” tai chi (6 of the 24
forms) 60‑minute progressing to 90‑minute sessions
(“work” time increased from 10 to 50 minutes) 2/week for 48
weeks
- Control group: Wellness education (general advice about falls
prevention, exercise and balance, diet and nutrition pharmacological
management, legal issues relevant to health changes in body function, and
mental health issues) 1 hour per week for 48 weeks (comparable contact time to
intervention group)
|
- No difference in risk of falling (all falls, relative hazard
adjusted for center 0.75; 95% CI, 0.52 to 1.08)
- Tai chi group had a lower risk of falls from month 5 through
month 12 (relative hazard adjusted for center 0.61; 95% CI, 0.40 to 0.94)
|
Not reported |
- Effectiveness of “intense” tai chi in frail people
may not reach the level seen in robust older adults taking part in less intense
tai chi (Wolf et al., 1996).
- No adverse events occurred during either intervention.
- Wellness education program may have motivated participants to
become more physically active and make other lifestyle changes affecting falls
risk.
|
Campbell et al., 2005 (9)
- To assess the efficacy and cost effectiveness of a home safety
program and a home exercise program to reduce falls and injuries in older
people with low vision
- Men and women aged >75 years, visual acuity 6/24 or
worse
- n=391; 361 (92%) completed 1-year follow-up
|
2 x 2 factorial design:
- Intervention group 1: Home safety assessment and modification
program delivered by an occupational therapist
- Intervention group 2: Exercise program (Otago Exercise
Programme) plus vitamin D supplementation
- Intervention group 3: Received both interventions
- Control group: Social visits
|
- Fewer falls occurred in the group randomized to the home safety
program but not in the exercise program (IRR 0.59 (95% CI, 0.42 to 0.83) and
1.15 (0.82 to 1.61) respectively).
- Within exercise program, stricter adherence was associated
with fewer falls (P=0.001).
- Neither group intervention was effective in reducing injuries
from falls.
|
– |
Vitamin D supplement was given to those in exercise group who were
not already taking it |
Li et al., 2005 (10)
- To evaluate the efficacy of a 6-month tai chi intervention for
decreasing the number of falls and the risk for falling in older persons.
- Men and women 70-92 years, inactive, independent ambulatory,
free of chronic medical problems that would limit participation in
low-to-moderate intensity exercise, physician’s clearance, no cognitive
impairments
- n=256
- 6 months, 6-month follow-up
|
- Intervention group: Classical Yang style tai chi taught by
experienced tai chi instructors 2/week for 6 months. Each session included
5‑10 minutes of a warm-up and cool-down and included musical
accompaniment.
- Control group: Low-intensity stretching, controlled breathing,
and relaxation exercises taught by qualified exercise instructors 2/week for 6
months.
|
At 6 months:
- Significantly fewer falls (n=38 vs. 73; P=0.007),
lower proportions of fallers
(28% vs. 46%; P=0.01), and fewer
injurious falls (7% vs. 18%; P=0.03) were observed in the tai chi
group compared with the stretching control group.
- After adjusting for baseline covariates, the risk for multiple
falls in the tai chi group was 55% lower than that of the stretching control
group (risk ratio, 0.45; 95% CI, 0.30 to 0.70).
- Compared with the stretching control participants, the tai chi
participants showed significant improvements (P <0.001) in all
measures of functional balance, physical performance, and reduced fear of
falling.
- Intervention gains in these measures were maintained at a
6-month post-intervention follow-up in the tai chi group.
|
– |
– |
Skelton et al., 2005 (11)
- To investigate the impact of a 36-week individualized and
tailored group and home exercise intervention, compared with a control
intervention, in reducing falls and injuries in community-dwelling,
independent-living, frequent falling women aged 65+ years.
- Women aged 65+ years, living in their own home without help,
with a history of 3 or more falls in the previous year
- n=81
- 12 months
|
- Intervention group: 36 weeks of Falls Management Exercise
(FaME) classes (balance specific) once a week for an hour. Followed Otago
Exercise Program at home (2/week, 30 minutes).
- Control group: Home exercise (2/week), seated warm-up,
mobility, flexibility, and cool-down exercises.
|
- There was a 31% reduction in the number of falls during the
whole trial period for the exercise group compared with the control group from
negative binomial regression model 0.69; 95% CI, 0.50-0.96, P=0.029).
However, on further analysis, this reduction was totally due to the 54%
reduction in falls in the follow-up period (IRR 0.46; 95% CI,
0.34‑0.63).
- The number of fallers among exercisers decreased progressively
from baseline through intervention to follow-up, while the number falling among
controls did not.
|
– |
– |
Voukelatos et al., 2007 (12)
- To determine the effectiveness of a 16‑week
community-based tai chi program in reducing falls and improving balance in
people aged 60 years and older
- Men and women aged 60+ years, living in the community, had not
practiced tai chi in previous 12 months
- n=702
- 16 weeks, 8 weeks follow-up
|
- Intervention group: Group tai chi classes (8-15 participants)
led by a tai chi instructor, 60 minutes 1/week. The majority of classes
(83%) involved Sun-style tai chi.
- Control group: Instructed not to do any tai chi.
|
- Falls were less frequent in the tai chi group than in the
control group. Using Cox regression and time to first fall, the hazard ratio
after 16 weeks was 0.72 (95% CI = 0.51-1.01, P=0.06), and after 24
weeks it was 0.67 (95% CI = 0.49-0.93, P=0.02).
- No difference in the percentage of participants who had one or
more falls.
- Statistically significant differences in changes in balance
favoring the tai chi group on five of six balance tests.
|
– |
– |
CI, confidence interval; IRR, incidence rate ratio;
SF-36, short form health survey with 36 questions Adapted with permission
from Blackwell Publishing, 2007, Oxford, UK. Published in the book:
Evidence-Based Sports Medicine. From the chapter written by Robertson M and
Campbell A, (chapter 9) entitled: What type of exercise reduces falls in older
people?
Reference List
- Wolf SL, Barnhart HX, Kutner NG, McNeely E,
Coogler C, Xu T. Reducing frailty and falls in older persons: an investigation
of Tai Chi and computerized balance training. Atlanta FICSIT Group. Frailty and
Injuries: Cooperative Studies of Intervention Techniques. J.Am.Geriatr.Soc.
1996 May;44(5):489-97.
- 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.Med.Sci. 1997
Jul;52(4):M218-M224.
- Campbell AJ, Robertson MC, Gardner MM, Norton RN,
Tilyard MW, Buchner DM. Randomised controlled trial of a general practice
programme of home based exercise to prevent falls in elderly women. BMJ 1997
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- Campbell AJ, Robertson MC, Gardner MM, Norton RN,
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- Robertson MC, Gardner MM, Devlin N, McGee R,
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exercise programme to prevent falls. 2: Controlled trial in multiple centres.
BMJ 2001 Mar 24;322(7288):701-4.
- Barnett A, Smith B, Lord SR, Williams M, Baumand
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controlled trial. J.Am.Geriatr.Soc. 2003 Dec;51(12):1685-92.
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Central Sydney tai chi trial. J.Am.Geriatr.Soc. 2007 Aug;55(8):1185-91.
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