1. Exercise and Falls Prevention: In different settings
Dr Dawn Skelton PhD
Reader in Ageing and Health, HealthQWest,
Glasgow Caledonian University
Co-ordinator of Prevention of Falls
Network Europe, University of Manchester

2. Exercise to Prevent Falls
Exercise could help fallers in a number of ways:
Reducing Falls (or injurious falls)
Reducing known Risk Factors for Falls
Reducing Fractures ? (or changing the site of fracture)
Increasing Quality of Life & Social Activities
Improving bone density
Reducing Fear
Reducing Institutionalisation
Gardner 2000; Skelton & Dinan 1999; Skelton & Todd, 2005; NICE 2004

3. C Sherrington, JC Whitney, SR Lord, RD Herbert, RG Cumming, JCT Close
Effective exercise for the prevention of falls – a systematic review and meta-analysis
C Sherrington, JC Whitney, SR Lord, RD Herbert, RG Cumming, JCT Close
44 RCTs participants
JAGS, 2008

4. Results RR = 0.83 17% reduction in falls 95%CI 0.75-0.91 P<0.001
Moderate heterogenity
I² = 62% moderate heterogeneity
Sherrington et al., JAGS 2008

5. What makes the difference?
Greatest effects of exercise on fall rates from interventions including:
Highly challenging balance training
High dose
No walking program
These 3 factors explained 68% of variance
Sherrington et al., JAGS 2008 in press

6. Highly challenging Balance Training
Exercise in standing involving:
movement of the centre of mass
narrowing of the base of support
minimising upper limb support
24%
Ratio of rate ratios
RR 0.76
(95%CI =0.62 to 0.93)
Sherrington et al., JAGS 2008 in press

7. High Dose
50+ hours
At least 2 hours a week of exercise for at least 6 months
Home or group-based or a combination of both
20%
Ratio of rate ratios
RR 0.80
(95%CI =0.65 to 0.99)
Sherrington et al., JAGS 2008 in press

8. Adjusted effects of exercise on falls
42% Reduction:
RR 0.58 (0.48 to 0.69)
High balance
High dose
No Walking
High balance
Low dose
No Walking
28% Reduction:
RR 0.72 (0.60 to 0.87)
Low balance
High dose
No walking
27% Reduction:
RR 0.73 (0.60 to 0.88)
High balance
High dose
Walking
24% Reduction:
RR 0.76 (0.66 to 0.88)

9. Adjusted effects of exercise on falls
No reduction:
RR 0.95 (0.78 to 1.16)
High balance
Low dose
Walking
Low balance
High dose
Walking
No reduction:
RR 0.96 (0.80 to 1.16)
Low balance
Low dose
No walking
No reduction:
RR 0.91 (0.79 to 1.05)
Low balance
Low dose
Walking
Increased risk:
RR 1.20 (1.00 to 1.44)

10. Should we target high or low risk people?
Trend towards better effect in low risk but no significant difference seen in high vs low risk groups
High risk groups may be more cost effective to treat as more falls per person per year prevented
Low risk groups could be targeted with a population based health promotion approach (greater reach) with the right messages (eg. Not just walking!)
Sherrington et al., JAGS 2008 in press

11. Just balance ? Type Mix Balance and/or mobility (Essential)
Resistance exercise (Very Important)
Lower limb
Most effective in weakest
Aerobic / Endurance (Important)
Flexibility (Important)
Functional Task Training (Important)
Mix
Endurance or resistance training alone does not work
Sherrington, 2008

12. Conclusions of Review
Highly challenging balance training is an essential component of falls prevention exercise
Exercise should take place at least twice a week for a minimum duration of 6 months
Additional strength training for people with muscle weakness and / or aged over 80
Programmes should be progressed as a participant improves
Walking should only be prescribed in addition to a high intensity / high dose programme
Sherrington et al., JAGS 2008

13. New Zealand RCTs - OTAGO
Individually tailored programme: Campbell, BMJ 1997
-80+ years, n=233, home-based, physiotherapist year, falls  32%, injuries  39%
Nurse delivered programme at home: Robertson, BMJ 2001
-75+ years, n= 240, home-based, district nurse
-1 year, falls  46%,  serious injuries and hospital costs
Nurse programme at GP centres: Robertson, BMJ 2001
-80+ years, n=450, home-based, general practice nurse
-1 year, falls  30%, injuries  28%
Physiological studies: Exercise shown to increase muscle strength and improve balance thus provide rational for using it to attempt tp reduce falls.
FICSIT metan.(5comm, 2 Nh)-Province 1999,2-4 yrs, dif progs,subjects assigned to an x gp less likely to fall. No x component sig for injurious falls
Cochrane review incons. Data. x alone did not protect against falls
Tai Chi: (Atlanta FICSIT): 48% reduction (adjusted for fall risk factors) cf computerised balance training programme(interestingly only controlgp improved balanced showing importance of fall as primary measure (Mcmurdo)
Campbell 1997: -cognitively intact, able to move around house hr visits over 2 months- individ 30 min progrm of strengthening exercises using ankle weights and balance training exercises included standing with one foot directlt in front of the other, walking tandem, heel walking, toe walking, knee squats. 3+ times a week and also walk outside home at least 3 times a week.
-also relative hazard for injurious falls reduced and balance scores improved
Campbell 1999 Age Ageing: rate of falls remained sig lower in the ex group than control gp at 2 years in those who continued the programme.
Robertson; Nurse home: serious injuries and hosp admissions reduced.
-cost /fall (1988 prices) Pv = NZ$1803 (£523) IRR = Inc rate ratio
-cost / fall averted considering hospital costs NZ$155 (£45)
Robertson: nurse. GP centres: no diff in serious injuries or hosp. Costs
-cost/ fall averted : NZ$1519 (£441)
Ebrahims 97, AgeAgeing brisk walking gp: falls up, therefore x is not x is not x. Qualified x practitioners-graded strengthening+ walking program
Visually Impaired Older People: Campbell, BMJ 2005
-1 year, home-based. Only effective with full compliance, falls 28%
6 month programme: Liu-Ambrose, JAGS 2008
-70+ years, home-based, cognitive function improvements after 6 months and after 1 year falls 47%

14. What might work….but we don’t know?
Just increasing habitual physical activity
Different types of balance challenge in less frail older adults
Bowls
Line / Country / Scottish Dancing
Working in an allotment
Cycling
Skiing
……etc

15. New technologies ? Wii-fit (Nintendo) ? Whole Body Vibration
6 mths, 3 x p/w
post-menopausal women
Strength 15%, Balance 20%,
Hip BMD 1%
Verschueren SM et al. 2004

16. Patients in Hospital
Tai Chi + reaching + stepping + transferring chair to chair
1 physiotherapist to max 4 patients, 3 x p/w, 45 mins.
173 patients, 82 yrs, sub-acute ward
Halved the number of falls (participant days in hospital)
Haines et al. Clin Rehab 2007

17. Exercise alone? In high risk
Not beneficial in care home residents
RR 1.16 [ ]
Sherrington et al, 2008
? Because the balance challenge is rarely great enough
Needs strength and power focus too?
Transfer training?

18. Part of a multi-factorial intervention…care homes
Reduces falls - Becker et al. JAGS 2003
Improves mobility - Jensen et al. Aging Clin Exp Res 2004
Reduces falls risk factors - Dyer et al. Age Ageing 2004
Works better in those with cognitive impairment!!! – Rapp et al. 2008

19. Increasing engagement with exercise ?
60 people attending A & E as a result of a fall. When offered choice on an intervention to prevent a future fall
72% reluctant to take up exercise programme
28% reluctant to take osteoporosis medication
But when asked if likely to take up an intervention to prevent a worsening health state
63% said they would take up exercise!
93% would take osteoporosis medication
Whitehead 2006

20. Avoidance of activity?
Falls prevention advice can induce anxiety and lead to activity restriction (AR)
Exercise interventions perhaps should take account of:
‘Selectors’
See AR as a sensible approach to cope with their balance problems –poor adherence to exercise
‘Optimisers’
Better uptake and adherence to exercise as see increasing activity as a good approach to reducing falls
‘Compensators’
Tend to just adjust the activities they do rather than increase activities – more likely to accept home environmental advice and assistive walking aids
Laybourne, Biggs, Martin, 2008

21. Changing Behaviour….. Adherence
Most of those who take part in a 6 month programme continue to be afterwards…..
Information and choice
Assessments, goal setting
Emphasize benefits to strength, balance and function rather than reducing falls
What to expect from exercise
Self efficacy
Social support
Ongoing supervision and support
Yardley L, 2007 (ProFaNE)
Sherrington, 2008

22. Final summary
Exercise that challenges balance and improves gait / strength / power is best
Exercise must be regular!
Exercise has to be FOR LIFE – not 6-12 weeks!
Exercise works even if people have many other medical risk factors
Exercise may not stop a trip becoming a fall, but it will help reduce the “impact” of the fall and help people get back up again
Exercise improves quality of life, social inclusion and helps autonomy and independence

23. 8th World Congress on Aging and Physical Activity
Aug
Glasgow, UK
“A celebration of diversity and inclusion in active ageing”