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Exercise in the Prevention of Falls in Older People: A Systematic Literature

Review Examining the Rationale and the Evidence

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REVIEW ARTICLE Sports Med 2001; 31 (6): 427-438
0112-1642/01/0006-0427/$22.00/0

© Adis International Limited. All rights reserved.

Exercise in the Prevention of Falls in

Older People
A Systematic Literature Review Examining the Rationale
and the Evidence
Nick D. Carter,1,2,3 Pekka Kannus4,5,6 and Karim M. Khan1,3,7
1 Department of Family Practice, University of British Columbia, Vancouver,
British Columbia, Canada
2 Defence Services Medical Rehabilitation Centre, Headley Court, Epsom, Surrey, England
3 School of Human Kinetics, University of British Columbia, Vancouver, British Columbia, Canada
4 The Bone Research Group, Accident and Trauma Research Center,
The President Urho Kaleva Kekkonen Institute for Health Promotion Research, Tampere, Finland
5 Department of Surgery, Medical School, University of Tampere, Finland
6 Department of Surgery, Tampere University Hospital, Tampere, Finland
7 Osteoporosis Program, BC Women’s Hospital and Health Centre, Vancouver,
British Columbia, Canada

Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
1. The Age-Related Physiological Changes that Increase Risk for Falling Among
Older People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
2. Integrated Rehabilitation-Based Model of Fall Risk Factors . . . . . . . . . . . . . . . . . . . . . . . 429
3. Can Exercise Modify the Risk Factors for Falling? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
4. Can Exercise Decrease Fall Rate? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
5. Which Dimensions of Exercise are Key to Reducing Fall Risk? . . . . . . . . . . . . . . . . . . . . . 432
6. Limitations in Present Research and Suggested Solutions . . . . . . . . . . . . . . . . . . . . . . . . 432
7. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435

Abstract Falls are a major source of death and injury in elderly people. For example,
they cause 90% of hip fractures and the current cost of hip fractures in the US is
estimated to be about 10 billion dollars. Age-related changes in the physiological
systems (somatosensory, vestibular and visual) which contribute to the mainte-
nance of balance are well documented in older adults. These changes coupled
with age-related changes in muscle and bone are likely to contribute to an in-
creased risk of falls in this population. The integrated rehabilitation-based model
of fall risk factors reveals multiple sites for interventions that may reverse fall
risk factors. Regular exercise may be one way of preventing falls and fall-related
fractures. The evidence for this contention comes from a variety of sources. On
the basis of 9 randomised controlled studies conducted since 1996, exercise ap-
pears to be a useful tool in fall prevention in older adults, significantly reducing
428
the incidence of falls compared with control groups. However, current limitations
such as inconsistencies in the measurement of key dependent and independent
variables do not, at present, permit a meta-analysis of intervention trials. Further
investigation, using trials designed with the current limitations in mind, is nec-
essary to establish the optimum exercise programme to maximise fall prevention
in older adults.
Fall-related injuries and deaths in older adults
are a major health problem worldwide,[1-4] with num-
bers of these injuries continuing to increase.[4] Ap-
proximately 30% of individuals over 65 years of
age fall at least once per year,[5,6] and about half of
these do so recurrently.[7] In nonfatal falls almost
half of fallers are unable to get up without help[8]
and a fall may result in individuals considerably
reducing their activities for fear of future falls.[9] In
addition, there is an alarming trend towards an in-
creasing aging population, suggesting that these
problems are likely to become even more prevalent
in the future.[10]
A proportion of falls result in fractures. Over
90% of hip fractures result from falls,[11,12] and in
individuals who sustain a hip fracture, the outcome
is fatal in 12 to 20% of cases.[13,14] In nonfatal cases,
long-standing pain, disability and functional impair-
ment often ensue with tremendous socio-economic
consequences. In the UK alone, the estimated total
direct hospital costs arising from hip fractures are
£1.3 billion (year of costing 2000),[15] and in the US
the annual costs associated with fall-related frac-
tures were estimated at $US10 billion.[1] Further-
more, the incidence of hip fractures continues to
rise steadily, even with age-adjusted figures.[16,17]
Regular exercise has been proposed as one method
of preventing falls and therefore fall-related frac-
tures in older adults.[18] However, a great deal of
controversy surrounds both this premise[19] and the
specifics of the exercise prescription (i.e. type, fre-
quency, intensity and duration of the exercise) nec-
essary to prevent falls. Therefore, the aim of this
systematic literature review is to:
• summarise the age-related physiological mech-
anisms that increase the risk for falling in older
adults
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Carter et al.
• improve understanding of the inter-relationships
between various fall risk factors by proposing
an integrated, rehabilitation-based risk factor
model
• summarise the mechanisms whereby exercise
may plausibly reduce fall risk
• systematically review the evidence as to whether
exercise can modify risk factors for falling and
influence fall rates
• examine which dimensions of exercise are key
to reducing fall risk
• propose directions for future research to address
the question: ‘Can regular exercise prevent falls
and fall-related injuries in older individuals?’
1. The Age-Related Physiological
Changes that Increase Risk for Falling
Among Older People
The incidence of falls increases with age.[2,4,7,20]
This is likely to be caused, in part, by age-related
deterioration of the 3 sensory systems that control
posture: vestibular, visual and somatosensory (fig.
1). The vestibular system provides input as to the
head position in relation to gravity and it also senses
how fast, and in which direction, the head is ac-
celerating. The visual system provides information
about the body’s location relative to its environ-
ment. The somatosensory system, in turn, is respon-
sible for discrimination of position and movements
of body parts. In the otolith of the ear, individuals
over 70 years of age have 40% fewer sensory cells
than do young adults.[21] Cutaneous vibratory sen-
sation and joint position sense are also significantly
diminished in the older person.[20,22] Peripheral vi-
sion is important in sway stabilisation,[23] and low
frequency spatial information, mediated by the pe-
ripheral visual field, deteriorates with age.[24]
Sports Medicine 2001; 31 (6)
Exercise and Fall Prevention in Older People
As well as involution of the sensory systems,
predisposition to both falls and fractures is also
likely to be increased by age-related changes in
muscle and bone. Studies have repeatedly found a
decline in lean muscle mass and strength in elderly
adults.[25-29] Overall muscle strength and mass de-
cline 30 to 50% between the ages of 30 and 80.[30]
As a result of the changes in muscle and sensory
function, 46% of adults 85 years and older and 36%
of adults over 75 years, complain of postural dis-
turbances compared with 13% of those aged 65 to
69 years.[31,32] Muscle mass and function are im-
portant for stability and correct balance, and are also
thought to give some protection to the proximal
femur by attenuating the hip-impact forces that oc-
cur in sideways falls in older adults.[33]
Although not a risk factor for falling, involu-
tional bone loss contributes to fracture risk, and
thus, warrants mention here. Cross-sectional stud-
ies indicate that bone loss commences in both sexes
from the middle of the third decade of life.[34-36] Of
many factors that may affect bone loss, menopause-
related sex-hormone deficiency is by far the most
important. In addition to the accelerated phase of
post-menopausal bone loss, a continuous, more grad-
ual process of age-related bone loss affects the hip
in both sexes and this may be caused by the effects
of reduced physical activity or the relative immo-
bility of the older adult.[37]
2. Integrated Rehabilitation-Based
Model of Fall Risk Factors
In excess of 130 different risk factors for falling
have been tabulated.[38] Because many of these risk
factors may be either directly correlated, or interact
in a complex manner, clinicians and scientists have
tried to group them in useful conceptual categories.
The simple dichotomy of risk factors for falling is
intrinsic, host factors (increased personal liability
to fall) and extrinsic, environmental factors (in-
creased opportunity to fall).[39,40] Extrinsic factors
have undoubted importance,[41] but have received
relatively little attention in medical strategies to
prevent falls.
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429
Vestibular system
Vision
Somatosensory
system
Fig. 1. The 3 sensory systems that control posture: vestibular,
visual and somatosensory. (Artwork by Vicky Earle.)
The act of falling comprises 3 stages; fall initi-
ation, fall descent and fall impact.[42] As different
factors can act at each stage of the fall process, this
categorisation provides several areas of focus for
medical intervention. This approach has, for exam-
ple, led to some researchers focusing on hip pro-
tectors to reduce fall impact, and thus, fracture
risk.[33]
In view of the complexity of interaction between
risk factors, we draw the reader’s attention to the
model of ‘impairment’ and ‘disability’. The World
Health Organisation (WHO) definition of impair-
ment is any loss or abnormality of psychological,
physiological or anatomical structure or function.
Disability, according to the International Classifi-
cation of Impairments, Disabilities or Handicaps
(ICIDH), and is defined as any restriction or lack
(resulting from impairment) of ability to perform
an activity in the manner or within the range con-
sidered normal for a human being.[43,44] Stroke, for
example, increases risk of falling, but it is muscle
weakness or sensory loss (impairment) and poor
balance (disability) resulting from the stroke that
produces the increased risk, not the stroke itself.
The terms ‘impairment’ and ‘disability’ are widely
used in rehabilitation medicine and they are partic-
Sports Medicine 2001; 31 (6)
430
Aging, disuse and
medical conditions
such as:
· Parkinson's disease
· stroke
· hypotension
· depression
· epilepsy
· dementia
· eye diseases
· osteoarthrosis
· rheumatoid arthritis
· dizzyness and vertigo
· peripheral neuropathy
Impairments:
· muscle function
· joint function
· vestibular system
· vision
· proprioception
· cognition
Disabilities:
· static balance
· dynamic balance
· gait
Reduced bone mass
Altered bone geometry
Altered bone architecture
Altered bone quality
Fig. 2. Intrinsic impairments and disabilities can interplay with environmental hazards and predispose individuals to falls and fractures.
ularly useful for understanding the mechanisms that
underpin falling.
A strength of the rehabilitation model is that it
reveals multiple sites for interventions that may re-
verse fall risk factors (fig. 2). Clearly reversible
risk factors (e.g. multiple drug therapy) can be at-
tended to directly. The rehabilitation model indi-
cates that irreversible risk factors (e.g., stroke, osteo-
arthrosis) can theoretically be tackled by targeting the
specific impairments (therapy to improve strength
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Carter et al.
Medication use,
such as:
· sedatives
· hypnotics
· antidepressants
· antihypertensives
· multiple drugs
· alcohol
Fall initiation
Fall descent
Environmental
Fall impact
hazards
Impact force attenuation
· soft tissues
· landing surface
Structural capacity of bone
less than the applied load
Bone fracture
and proprioception) and the resultant disabilities
(therapy to improve gait). Thus, risk of falling may
be modifiable, even though the underlying medical
condition may not be. We believe that the integrated
model clarifies a field that can seem confusing when
risk factors are viewed in isolation.
Using this model, table I summarises some of
the many studies reporting specific impairments
and disabilities that predispose to falls and the rel-
ative risk for falling that each risk factor imparts.
Sports Medicine 2001; 31 (6)
Exercise and Fall Prevention in Older People 431

In each impairment or disability, the relative risk edge of this topic. A total of 13 studies were iden-
for falls was determined according to dichotomous tified that had:
division (normal, abnormal) of continuous variables, • randomised controlled trial design
although the cut-off point varied between studies. • participants 60 years or older
Figure 2 then summarises how intrinsic impairments • falls as an outcome
and disabilities, associated with aging and disease, • exercise as intervention.
can mesh with extrinsic factors in predisposing to If exercise was included as part of a multifacto-
falls and fractures. rial intervention, it was analysed only when the ex-
ercise component could clearly be separated from the
3. Can Exercise Modify the Risk Factors other interventions.
for Falling?
From figure 2, it can be seen that intervention 4.1 Results
strategies to modify risk factors for falls can be im-
Table III describes 13 randomised controlled trials
plemented in a number of areas. Multifactorial hazard
using exercise as the intervention for fall prevention
reduction interventions have reduced falls,[41,71,72]
in community (n = 12) or institution dwelling (n =
as have reductions in the number of medications
1) older adults. The table reveals that the studies prior
that elderly people use.[73] Multifactorial interven-
to 1996 did not find that exercise reduced the risk
tions do not allow investigators to distinguish the
of falling in older adults while the 9 more recent
independent role of each modified risk factor, and
studies (since Wolf et. al.[117]) confirmed the value of
thus, it is not known which part of the intervention
exercise in fall prevention. Five studies demonstrated
is effective and which is not. Also, these multifac-
a significant reduction in falls[104,117,118,120,123] whilst
eted approaches are labour intensive and their cost-
in the remaining 4,[73,119,121,122] some reduction in
effectiveness must be evaluated further.[41,74]
falls was evident but not statistically significant. In
Exercise intervention can reduce many intrinsic
the Wolf et al.[117] study, a programme of Tai Chi
risk factors for falling (table II). Myers et al.[38] sug-
resulted in a 48% reduction of falls in participants
gested that strength, flexibility, balance and reaction
(mean age 76 years) compared with controls. Such
time were the factors most amenable to modification,
a reduction was not seen in the individuals who
and thus, provide a rationale for exercise interven-
followed a computerised balance-training pro-
tion trials measuring the efficacy of exercise in the
prevention of falls in the elderly.
Table I. Impairments and disabilities as risk factors for falls
4. Can Exercise Decrease Fall Rate? Risk factor for falling Relative risk References
for falls (range
To address the question ‘Does exercise interven- between studies)
tion reduce fall rate?’ we performed a computerised Impairment
literature search of the entire MEDLINE database, Lower limb strength 0.5-10.3 6,45-49
covering the years 1966 to the present, using the Upper limb strength 1.5-4.3 3,6,9,50,51
keywords: randomised controlled trials, exercise, Lower limb range of 1.9 3
motion
falls and elderly. All relevant articles were retrieved,
Sensation 0.6-5.0 45,47,52,53
either locally, or by inter-library loan. The search
Vestibular function 4.0 54
was not limited to the English literature, and articles Vision 1.3-1.6 3,6,51,53,55-60
in all journals were considered, as were the refer- Cognition 1.2-5.0 5,6,58,61-65
ence lists of the published papers. Any relevant per-
Disability
sonal correspondence was also included. The refer- Static balance 1.5-4.1 5,6,46,48,51,66-68
ences selected were reviewed by the authors, and Dynamic balance/gait 1.6-3.3 3,5,6,9,48,50-52,65,
judged on their contribution to the body of knowl- 68-70

 Adis International Limited. All rights reserved. Sports Medicine 2001; 31 (6)
432
Table II. Intervention studies which have used exercise to modify
intrinsic risk factors for falls
Risk factor Average improvement (%) References
for falling [range between studies]
Muscle strength 6-174
Range of motion 0.5-18
Balance –7-53
Gait 12-48
Reaction time 0-4
gramme. It is of interest that whilst the computer-
ised balance-training group developed greater sta-
bility on balance platform measures there was little
change in this parameter in the Tai Chi group.[124]
In the study by Campbell et al.[104] a physiotherapist-
led, but individualised programme of predominant-
ly lower limb strength and balance exercises for 30
minutes, 3 times per week plus additional walking,
resulted in a significantly reduced annual rate of
falls among women aged 80 years and older, com-
pared with control women. After 1 year, the relative
hazard for the first 4 falls in the exercise group
compared with controls was 0.68. The benefit of
exercise for the reduction of falls continued in the
2-year follow-up.[120] Buchner et al.,[118] in turn,
reported that in 75 community-dwelling elderly in-
dividuals who underwent strength, endurance and
flexibility training, fewer persons fell in the first
year (42%) compared with controls (60%) [p < 0.05].
These data were originally presented comparing 3
exercise groups (each with 25 participants; strength
and flexibility, endurance and flexibility, and also
strength and endurance) with controls as part of the
Frailties and Injuries: Co-operative Studies of In-
tervention Techniques (FICSIT) meta-analysis (in
which 7 independent, randomised, controlled trials
assessed intervention efficacy in reducing falls).[125]
Analysis by these individual groups did not dem-
onstrate a significant reduction in the incidence of
falls.
In the meta-analysis of the 7 FICSIT trials, there
was a reduction in the fall incidence ratio (IR) for
treatment arms including exercise (IR = 0.90) and
balance (IR = 0.83).[125] However, repeat meta-
 Adis International Limited. All rights reserved.
Carter et al.
analysis excluding interventions with a nonexerc-
ise component, revealed that although the effects
of balance training remained (IR = 0.75), the pooled
41,75-100
estimate for overall exercise became nonsignificant
84,93,96,101-103 at IR = 0.87. There was no significant effect of the
41,77,83,86,90-94, other exercise domains (resistance, endurance and
96,101,104-113 flexibility) on the IR for falls.[125]
41,76,87,94,96,98, In 5 additional studies, to the 13 studies described
99,108,109,113,114
77,91,115
in table III, the exercise intervention arm combined
exercise with the correction of intrinsic (smoking/
alcohol/nutrition,[126] drug treatment[41]) risk fac-
tors or extrinsic (environmental hazards[126-129]) risk
factors. As the effect of exercise cannot be sepa-
rated from the other components of the multifacto-
rial intervention, these studies cannot be analysed
further in terms of exercise and fall prevention.
5. Which Dimensions of Exercise are
Key to Reducing Fall Risk?
Exercise and physical activity can be defined by
4 dimensions: type, frequency, intensity and dura-
tion.[130] Thus, we examined the 13 randomised con-
trolled trials outlined in table III to see whether the
interventions that reduced fall risk had certain ex-
ercise dimensions in common (table IV). Clearly,
the paucity of exercise dimension data and the lim-
ited power of studies undertaken to date, preclude
definite conclusions from being drawn and precise
exercise programmes from being prescribed. Al-
though, it is most encouraging that all of the more
recent studies found exercise to be a useful tool in
fall prevention in older persons (table III).
Exercise interventions in the meta-analysis of
the 7 FICSIT trials pooled effect estimates of the
individual training types across the studies. Pool-
ing indicated a lower fall IR for balance, resistance
and flexibility training than for endurance training.
However, it must be noted that the confidence in-
tervals overlapped.[125]
6. Limitations in Present Research and
Suggested Solutions
One of the major limitations in fall research is
inconsistency in the approach to measuring key de-
pendent and independent variables such as cogni-
Sports Medicine 2001; 31 (6)
Exercise and Fall Prevention in Older People 433

Table III. Summary of the randomised controlled trials that included exercise as an independently analyzed part of the trial in reducing or
delaying falls in older people
Author, date Participants: n, Intervention Falls outcome
dwelling type
[mean age (y)]
Reinsch et al., 230, C [74] (In) 3 groups: exercise (n = 57), (In) exercise (reported falling) = 24.7%;
1992[116] exercise/cognition (n = 72), cognition = 19.1%; exercise/cognition= 37.1%
cognition/behavioural (n = 51).
Exercise: 60 min, 3× per wk, 12mo. Stand-up,
step-up, stretching and movement to music.
Cognition/behavioural: health and safety
curriculum to prevent falls, relaxation, video
games. Exercise/cognition: 2× per wk exercise,
once per wk cognition
(Ct) n = 50 (Ct) = 19.1% (NS)
MacRae et al., 80, C [>69] (In) n = 42, stand-up/step-up routine progressing Fallers in 12mo period: (In) = 36%, (Ct) = 45%
1994[92] to 4 sets of 10 repetitions. (NS)
60 min 3× per wk
(Ct) n = 38, hourly meeting each wk focusing on
health promotion and safety education
Mulrow et al., 194, I [>81] (In) n = 97, individually tailored one-one Total number of falls: (In) = 79, (Ct) = 60 (NS).
1994[93] physiotherapy sessions 3× per wk for 4mo, Individuals with falls (%): (In) = 43, (Ct) = 37
including range of motion, strength, balance, (NS)
transfer and mobility. Each session 30-40 min
(Ct) n = 97, same frequency friendly visits
Lord et al., 1995[77] 197, C [72] (In) n = 100, 60-min exercise sessions, twice 1 or more falls: (In) = 34.7%, (Ct) = 35.1%
weekly in 4 terms of 10-12wk. 4 sections per (NS). 2 or more falls: (In) = 10.7%, (Ct) =
session: warm-up, conditioning (aerobic, 12.8% (NS)
strength, balance and flexibility), stretching
and relaxation
(Ct) n = 97
Wolf et al., 1996[117] 200, C [80] (In) 2 groups: Tai Chi (TC) [n = 72] 15 min twice Risk ratio of time to 1 or more falls as
daily at home for 4mo; computerised balance compared with controls: (TC) = 0.525 (47.5%
training (BT) [n = 64] reduction in fall incidence) p<0.01). (BT) =
(Ct) n = 64, education sessions once per wk 1.136 (NS)
Campbell et al., 232, C [84] (In) n = 116, individually tailored programme of Total falls: (In) = 88, (Ct) = 152. Rate of falls per
1997[104] exercise. Physiotherapist visited 4× in first 2mo. year: (In) = 0.87 [SD 1.29] (Ct) = 1.34 [SD
Exercises 3× per wk, 30 min each, lower limb 1.93], difference 0.47 (p < 0.05)
strength and balance plus encouraged walking
outside 3× per wk
(Ct) n = 116, equal care and frequent social visits
Buchner et al., 100, C [78] All individuals had at least mild deficits in 3 intervention groups analyzed as 1 group.
1997[118] strength or balance. (In) 3 groups: (S) strength Falls in the first year: (In) = 42%, (Ct) = 60%.
and flexibility [n = 25], (E) endurance and Relative risk in the intervention group 0.53 (p <
flexibility [n = 25], (SE) strength and endurance 0.05)
(n = 25). Strength training: upper and lower limb.
3 sessions per wk for 60 min. Endurance
training: stationary cycle 75% max. heart rate
(Ct) n = 25
McMurdo et al., 118, C [65] (In) 45 min weight-bearing exercise to music, Falls: (In) = 15, (Ct) = 31 (NS at 2y). Difference
1997[119] 3× per wk for 3× 10wk terms for 2y between groups from 12 to 18mo (p = 0.011)
(Ct) calcium supplementation (1000mg daily)
Campbell et al., 93, C [>75] (In) 3 groups: gradual psychotropic withdrawal Individuals with falls: (In) drug withdrawal =
1999[73] over 14wk plus home-based programme of 30% (p < 0.05), exercise = 39% [NS], (Ct) =51%
exercises (see[104]) [n = 24], drug withdrawal
only (n = 24), exercise only (n = 21).
(Ct) n = 24 Continued over page

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434 Carter et al.

Table III. Contd

Author, date Participants: n, Intervention Falls outcome
dwelling type [age
(y)]
Campbell et al., 152, C [84] 2y follow-up of the above 12mo study.[104] Total falls over 2y: (In) = 138, (Ct) = 220. Rate
1999[120] (In) n = 71, individually tailored programme of of falls per person year: (In) = 0.83 [SD 1.29],
exercise. Physiotherapist visited 4× in first 2mo (Ct) = 1.19 [SD 1.93]. Relative hazard for falls
of the original study. Exercises 3× per wk, 30 min for the exercise group at 2y = 0.69 [95% CI for
each, lower limb strength and balance plus (In) group compared with (Ct) 0.49, 0.97].
encouraged walking outside 3× per wk Relative hazard for a fall resulting in moderate
(Ct) n = 81, equal care and frequent social visits or severe injury = 0.63 (95% CI, 0.42, 0.95)
Steinberg et al., 252, C [75% 12 month follow up. (In) 3 groups: exercise to Fall events per 100 person months:
2000[121] aged 50-74, 25% improve balance and strength, frequency and (In) exercise = 6.37, (Ct) = 7.05. Time to first
aged >75] duration of exercises not defined (n = 69); home fall, adjusted hazard ratio: 0.67 (95% CI 0.42,
safety advice to modify environmental hazards 1.07)
(n = 61); medical assessment to optimise health
(n = 59)
(Ct) n = 63, education and awareness of fall risk
factors
Rubenstein et al., 59, C [75] 12wk follow-up. (In) n = 31; strength, endurance, (In) 38.7% reported falling, (Ct) 32.1% reported
2000[122] mobility and balance training for 90 min, 3× per falling (NS). Falls adjusted for activity:
wk for 12wk (In) 6/1000hr activity; (Ct) 16.2 (p < 0.05)
(Ct) n = 28, usual activities for the follow-up
period
Lehtola et al., 131 C [70-75] Additional 4mo follow-up after 6 month Relative hazard for falls for the exercise group
2000[123] intervention. (In) n = 92, an exercise class in 10mo = 0.60 [95% CI for (In) compared with
including Tai Chi once weekly plus walking with (Ct) 0.43, 0.84]
sticks, and home exercises each at least
3× weekly for 6mo
(Ct) n = 39, usual activities for the follow-up
period
C = community-dwelling; CI = confidence interval; Ct = control group; I = institution-dwelling; In = intervention group; n = number of participants;
NS = not significant; p = significance level; SD = standard deviation.

tion, vision, balance and strength. Furthermore, re-
porting falls data is sometimes prospective, some-
times short term retrospective, and sometimes long
term retrospective.[2] The definition of falls is gen-
erally agreed upon but it would advance the field
greatly if there was a collaboration on methodol-
ogy. If this were the case, it would permit a meta-
analysis of intervention trials. A meta-analysis would
be most beneficial given that absolute fall rates are
low and studies must be very large to have suffi-
cient power to detect differences between groups
in fall rates after intervention.
The preceding discussion of exercise interven-
tion studies undertaken to date reveals significant
deficiencies in the literature with respect to fall pre-
vention in older adults. The oldest individuals are
particularly at risk of fall-related fractures,[41] and
therefore, fall prevention studies in this population
are urgently required.
Given the broad range of extrinsic and intrinsic
risk factors implicated in falls, it is extremely dif-
ficult to consciously control for all potentially con-
founding variables when assessing a single inter-
vention, such as exercise.[2] Therefore, randomised
controlled trials are essential. Nevertheless, future
studies should also attempt to guarantee equal group
distribution by cognition, vision, other medical con-
ditions, drug use, previous activity levels and en-
vironmental hazards. Stratified randomisation might
be used for this purpose.
As no definitive exercise prescription can be made
on the basis of studies published to date, further
work is required to establish the optimum exercise
programmes to prevent falls both in healthy older

 Adis International Limited. All rights reserved. Sports Medicine 2001; 31 (6)
Exercise and Fall Prevention in Older People 435

adults and in those with impairments and disabili- Table IV. Exercise dimensions in the positive and negative outcome
studies using exercise in the prevention of falls
ties.[2] For example, a once-weekly resistance train-
ing program has been shown to improve strength Exercise Studies in which falls Studies in which falls
dimension were reduced were not reduced
and neuromuscular performance in older adults.[75]
Type of activity
This programme is very attractive, as the frequency
Endurance 118,122 77,119
may promote programme adherence, though no stud- Strength 104,118,120,122 73,77,92,93,116,119,121
ies have yet been performed using this programme Balance 104,117,120,122,123 73,77,92,93,116,121
and measuring falls as an outcome. Furthermore, Flexibility 104,118,120 77,92,93,116,119
such exercise programmes need to be accessible Duration per session (min)
(e.g. home or community centres) to target popu- 15 117
lations so that the results from these projects can 30 104 73
be easily translated into clinical practice. 40 123 93
Future research that attempts to answer the ques- 45 119
60 118,123 77,92,116
tion: ‘Can exercise prevent falls among older adults?’
90 122
must clearly include an accurate assessment of both
falls[131] and fall-related injuries[41] as primary out- Frequency of exercise (times/wk)
2 77
come measures. Evidence exists that whilst fall risk
3 104,118,122 73,92,93,116,119
factors such as balance and strength may improve 4-7 123
with exercise,[76,77] falls themselves need not be 14 117
reduced and likewise, a reduction in falls may not
always be accompanied by a reduction in fall risk
factors.[117] In addition, fracture data have rarely ulation, better control for confounding vari-
been collected in relation to fall studies,[41,127,132] ables, identify an optimal exercise programme
and therefore future studies should ideally be of for specific groups of at-risk populations, and
sufficient power to detect a difference in fracture use falls and fractures as fall-related injury pri-
rates in the study populations, if any exists.[133] mary outcomes. To achieve these goals will re-
quire the collaboration of researchers from
7. Conclusion multiple centres.
• Falls and related fractures are a major health
problem for older individuals and for modern Acknowledgements
society. Dr Carter was supported as an Royal Air Force Fellow
• Involutional changes in sensory and musculo- while undertaking this research at the University of British
skeletal structure and function among older peo- Columbia (Allan McGavin Sports Medicine Centre and School
of Human Kinetics. The ‘Fall-Free BC’ Research Program is
ple render them at increased risk of falls and supported by the Vancouver Foundation (BCMSF), the BC
injuries. Sports Medicine Research Foundation, and the Canada Foun-
• Many intrinsic and extrinsic risk factors for falls dation for Innovation.
have been identified.
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Correspondence and offprints: Karim Khan, MD, PhD, De-
partment of Family Practice (Sports Medicine) and School
of Human Kinetics, University of British Columbia,
Mather Building, 5804 Fairview Ave, Vancouver, BC, V6T
1Z3, Canada.
E-mail: kkhan@interchange.ubc.ca
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