Functional performance and falls in the elderly – an example of two exercise interventions

Falling and fall-induced injuries are a major public health problem. For example, in Finland the number of deaths due to falls (1971-2009)¹ and the age-adjusted and age-specific incidence of fall-induced severe cervical spine injuries (1971-2011)² have increased in adults, aged 50 and older, in both men and women. Lower extremity and trunk muscle strength, brisk physical activity, static balance and a number of other diseases are associated with dynamic balance, functional performance and falls in elderly women^{3, 4}.

Multimodal training, combining strength and balance training, might not decrease the rate of falls, however it seems to significantly decrease the prevalence of falls that demand medical attention⁵. Multimodal training can enhance physical functioning, for example increase muscle strength, dynamic balance and prevent age related functional decline in the community-dwelling elderly woman^5,6 .  The training effects of multimodal group-training are dose dependent, but the gains achieved can be maintained with minimized supervised training that is supplemented by home exercises⁵.

Examples of successful and feasible exercise interventions:

The exercise interventions used by Patil (2015) and Karinkanta et al. (2007) were similar and both were concluded to be safe and feasible in the healthy community-dwelling elderly (70+ years). Both interventions included supervised strength training and progressively demanding balance training. Strength training included the main muscle groups of the body, with the focus on lower extremity, using weight machines, pulleys and free weights. In the intervention by Patil (2015) the supervised training was supplemented by home exercises.

The intensity of the resistance training programs used were set at 50 – 60% of 1RM, increasing to 75 – 80% of 1RM after 6 weeks in the intervention by Karinkanta et al. (2007). The intensity was increased by load or repetitions if RPE dropped under 18. Patil (2015) used more moderate intensity, starting the first four weeks with 30 – 60% of 1RM and increasing up to 75%. Intensity was increased by lowering repetitions and increasing load, and target RPE was between 14 to 18.

In the intervention by Karinkanta et al. (2007) the exercise frequency was three times a week, starting with two sets of 10 to 15 repetitions and progressing to 3 sets of 8 to 10 repetitions (with 2 min. rest period). Patil (2015) started with two times a week  for one year, and decreased the frequency to once a week for the second year. Two sets of 8 to 12 repetitions of 8 to 9 exercises (with 2 min. rest period) was used⁵. Some balance training was included in the warm-up⁵. In the intervention by Patil (2015) subjects also received a home exercise program (HEP) that consisted of modified versions of exercises completed during supervised sessions, for an approximate duration of 5 to 15 minutes. The HEP was performed on all days, except for days when supervised training was provided, in the first year and 3 times a week in the second year.

The balance training part of the interventions included balance and functional training and agility exercises^5,6 strengthening⁵, changes of direction and  impact exercises⁶ with  progressively increasing difficulty.  For example in the intervention by Patil (2015), especially in the beginning, support was used and later difficulty was increased with different surfaces, multidirectional movement patterns, dual-tasking, steps with varying heights and external weights. As training advanced, it also became more aerobic in nature.

Now that examples of how to plan the program, intensity, frequency and type of exercises have been presented, all that is left to do is produce clear exercise instructions for clients to follow. Excellent exercises for resistance training, balance and home exercise programs can be found, for example, in the following PhysioTools modules.

• Balance & Falls Prevention
• Falls Prevention with Pulley Equipment by HUR Ltd
• Fitness Training for Falls Prevention by Gerd Laxåback
• 55+ Gym Training by UKK Instituutti
• 55+ Motor Control & Balance by UKK Instituutti
• Fitness and Sports Therapy

References

1. Korhonen, Kannus, Niemi, Palvanen, Parkkari. Fall-induced deaths among older adults: Nationwide statistics in Finland between 1971 and 2009 and prediction for the future. Injury, Int J Care Injured 2013 44: 867–871.
2. Korhonen, Kannus, Niemi, Parkkari, Sievänen. Rapid increase in fall-induced cervical spine injuries among older Finnish adults between 1970 and 2011. Age and Ageing 2014; 43: 567–571.
3. Karinkanta S, Heinonen A, Sievänen H, Uusi-Rasi K, Kannus P. Factors Predicting dynamic balance and quality of life in home-dwelling elderly women.
4. Granacher U, Gollhofer A, Hortobágyi  T, Kressig R,  Muehlbauer T. The Importance of Trunk Muscle Strength for Balance, Functional Performance, and Fall Prevention in Seniors: A Systematic Review. Sports Med 2013;43:627–641.
5. Patil R. (2015).  Exercise in older women. Effects on Falls, Function, Fear of Falling and Finances. Academic dissertation, Acta Universitatis Tamperensis 2098. Tampere: Suomen Yliopistopaino Oy – Juvenes Print. (http://urn.fi/URN:ISBN:978-951-44-9918-0)
6. Karinkanta S, Heinonen A, Sievanen H, Uusi-Rasi K, Pasanen M, Ojala K, Fogelholm M, Kannus P. (2007). A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: Randomized, controlled trial. Osteoporos Int, 18(4), 453–462.