Original article 41
Combining Russian stimulation with isometric exercise
improves strength, balance, and mobility in older people
with falls syndrome
Myrope Sanjuán Vásqueza, María de la Luz Montes-Castilloa,
Leonor Elia Zapata-Altamiranob, Sara Martínez-Torresa,
Janitzia Vázquez-Melladoc and Carlos Omar López Lópeza
One of the main causes of falls in older people is muscle
strength loss associated with aging. Russian stimulation
can improve muscle strength in healthy individuals, but the
effect has never been tested in older individuals with falls
syndrome. The aim of this study was to evaluate the
usefulness of Russian stimulation plus isometric exercise
to improve muscular strength, balance, and mobility in older
people with falls syndrome. The recruited participants (older
than 60 years, at least one fall in the past year) were
evaluated by a physiatrist, who collected clinical data and
performed baseline and final evaluations (muscle strength,
Berg balance scale, Tinetti mobility test, get up and go test,
and 6-min walk test). A physical therapist applied the
10/50/10 protocol for Russian stimulation, stimulating the
quadriceps and tibialis anterior muscles separately;
simultaneously, the participants performed isometric
exercise at a frequency of three sessions per week for
12 weeks. Descriptive statistics, the paired-sample t-test,
and the χ2-test were performed. The study included 25
participants (96% women, mean age 65.2 ± 5.5 years). After
the intervention, there was a significant improvement in the
strength of the quadriceps (~30%) and tibialis anterior
(~40%) muscles as well as the results of the balance
Introduction
According to data from the WHO, the world’s population
over 60 years of age will increase from 605 million in 2000
to two billion in 2050 (World Health Organization, 2007).
Falls among older people are considered one of the most
serious and expensive public health problems worldwide
in terms of morbidity and mortality, with enormous costs
to health and social services (Kumar et al., 2008).
Approximately 30% of adults over 65 years who live in the
community suffer a fall at least once a year, and of these,
50% will suffer a new fall. Twenty-four percent of those
who fall have serious injuries and 6% have fractures
(Tinetti et al., 1988). The prevalence of falls varies with
age, the presence of frailty, and the environment; although
many reported falls in the older population have a known
precipitating factor, most of them are secondary to the
association of different factors (Lavedán Santamaría et al.,
2015). Older individuals with a history of falls experience
fear because of the possibility of a subsequent fall, which
0342-5282 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
(Tinetti 22%, Berg 10%) and mobility (get up and go
25%, 6-min distance 20%) tests. On the basis of the
improvements in the Tinetti and Berg scores, significantly
fewer participants were classified as being at increased risk
for falls. The muscle strength correlated with several clinical
evaluation results, but not with the Tinetti test score.
Russian stimulation plus isometric exercise improves
strength, balance, and mobility, which may decrease the
fall risk. International Journal of Rehabilitation Research
42:41–45 Copyright © 2018 Wolters Kluwer Health, Inc. All
rights reserved.
International Journal of Rehabilitation Research 2019, 42:41–45
Keywords: falls syndrome, muscle strength,
neuromuscular electrical stimulation, older people, Russian stimulation,
strengthening programs
a
Rehabilitation Department, bGeriatrics Department and cRheumatology Department,
Hospital General de México, Dr Eduardo Liceaga, Ciudad de México, México
Correspondence to Carlos Omar López López, PhD, MD, Rehabilitation
Department, Hospital General de México ‘Dr Eduardo Liceaga’, Dr Balmis148,
Col Doctores, Del. Cuauhtémoc, CP 06726 Ciudad de México, México
Tel: + 52 552 789 2000 x6119; e-mail: c.lopez.8108@gmail.com
Received 23 April 2018 Accepted 17 September 2018
could limit their activities and mobility, because of poor
muscle strength (Tinnetti and Speechly, 1989).
Currently, muscle strength loss associated with aging plays
an important role as a major cause of disability and has
emerged as one of the most frequent health problems in
older people. Furthermore, loss of muscle mass is one of
the most important bodily changes related to age, and there
is growing evidence that reduced muscle mass contributes
toward functional deterioration (Hayashida et al., 2014).
Physiological changes in the musculoskeletal system
observed in older people are a consequence of neuronal
and morphological modifications. Neural changes include
reduced maximal activation of agonist muscles, increased
coactivation of antagonist muscles, neuronal loss, and
muscle denervation. Morphological changes include a
decrease in the diameter of type II fibers and a decrease
in the length of the fascicles. These physiological chan-
ges cause limitations in muscle quality and functional
DOI: 10.1097/MRR.0000000000000321
42 International Journal of Rehabilitation Research 2019, Vol 42 No 1
capacity in older people (Aagaard et al., 2010; Pinto et al.,
2014).
Strength training is a potential intervention to counteract
sarcopenia and dynapenia associated with aging. Improved
strength is the result of (i) neuronal adaptations that increase
the maximum recruitment and firing frequency of the motor
unit and (ii) an increase in muscle mass and volume, which
results in improved muscle quality (strength and volume)
(Abe et al., 2000; Kamen and Knight, 2004).
Neuromuscular electrical stimulation has been used in
rehabilitation to improve muscle strength; moreover,
electrical stimulation combined with voluntary exercise
(isometric or isotonic) has been shown to be effective
for increasing muscle strength in healthy individuals
(Holcomb, 2006; Park and Hwangbo, 2015). Kramer (1982)
tested Russian stimulation in elite athletes, and after
neuromuscular stimulation, the participants had 40% more
strength. Muscle strength improvement has been shown
in young individuals and athletes after neuromuscular
stimulation plus voluntary exercise (Snyder-Mackler et al.,
1995; Ward and Shkuratova, 2002).
The aim of this study was to evaluate the usefulness of
Russian stimulation plus isometric exercise to improve
muscular strength, balance, and mobility in older people
with falls syndrome.
Patients and methods
Older people over 60 years old who agreed to participate
were included in the present study. The inclusion criteria
were as follows: patients referred from the outpatient ger-
iatrics department with falls syndrome diagnosis (at least
one reported fall without apparent etiology in the last year)
(Tinetti, 2003), controlled chronic diseases (e.g. diabetes
mellitus and systemic hypertension), independent walking,
having 50% range of motion in the hip, knee, and ankle
joints, with a muscle strength of 3 + /5 in quadriceps,
tibialis anterior, gluteus, and hamstrings (Medical Research
Council), and understanding the indications for exercise.
This study was reviewed and approved by our Hospital
Ethics and Research Committees and all participants
signed the consent form.
Clinical evaluation
A physician who is a specialist in Physical Medicine and
Rehabilitation evaluated all participants, collected their
sociodemographic data, and performed the baseline and
final functional evaluations:
(1) Muscle strength was evaluated of the quadriceps and
tibialis anterior muscles using a Hydraulic Push-Pull
Dynamometer, 50 lbs. 23 kg Dial Gauge (Chattanooga,
Vista, California, USA) and was measured in kilograms.
(2) The Berg balance scale consists of 14 items with
different difficulty – from sitting in a chair to standing
on one leg. Every item is scored from 0 to 4 and they
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
are added up to yield a total score between 0 and 56, a
higher score indicating better balance. This test takes
∼ 10–15 min to complete and is commonly used to
measure balance in individuals with varying conditions
and disabilities (Downs, 2015).
(3) The Tinetti mobility test is a reliable and valid
clinical test that measures balance and gait in older
people. It includes static, dynamic, reactive, and
anticipatory balance and ambulation and transfer
ability. The test can be taken within 5 min, and it is
frequently incorporated into comprehensive geriatric
assessments (Curcio et al., 2016).
(4) The get up and go test (GUGT) consists of performing
the following actions: getting up from a chair, walking
3 m, passing around a cone, and returning to the chair as
quickly as possible. The time that the patient needs to
carry out the sequence of movements is recorded
and the individual is classified as follows: less than
10 s = independent to mobility, 10–19 s = mostly inde-
pendent to mobility, 20–29 s = variable mobility, and
more than 30 s = reduced mobility. This is a simple tool
that evaluates function and fall risk in older people and
that shows good correlation with functional mobility
and balance. A required time of more than 14 s was
considered to be associated with an increased risk of
falls in older people (Mathias et al., 1986; Podsiadlo and
Richarson, 1991; Weiss et al., 2011).
(5) The 6-min walk test measures the time in seconds
that the patient takes to travel 10 meters in a straight
line. An average speed of less than 1 m/s is a predictor
of adverse events in older people. A gait speed
greater than 0.8 m/s correlates with a good capacity of
walking outdoors (Pasma et al., 2014).
The same specialist performed the baseline and final
evaluations to reduce bias.
Interventions
A physical therapist applied the Russian stimulation
according to the ‘10/50/10’ protocol (10 s of stimulation,
followed by 50 s of rest, repeated for 10 min). The sti-
mulation was delivered through carbon rubber electrodes
placed over the motor points of the vastus medialis,
vastus lateralis, rectus femoris, and tibialis anterior mus-
cles. During the stimulation of each muscle, the partici-
pant was asked to produce a maximum, palpable, visible,
and sustained contraction without moving the joint (knee
in 0°–10° extension, ankle at 90° dorsiflexion). The
intervention was administered three times per week for
12 weeks. We selected these muscles because of their
role in stabilizing the knee and ankle joints during nor-
mal gait (Brunner and Rutz, 2013).
Muscle electric stimulation
We used a Chattanooga Intelect Advanced Combo
(Chattanooga, Vista, California, USA) to perform Russian
 Russian stimulation in older people Sanjuán Vásquez et al. 43

current stimulation. A carrier wave of 200–2500 Hz was Table 1 Clinical evaluations: baseline and response to intervention
used, modulated in 50-Hz wave trains, each lasting 20 ms, Baseline Final evaluation
with a pulse duration of 33–440 µs, stimulus periods of Variables evaluation (n = 25) (n = 25) P value
10 s (2 s ascent ramp, 5 s maximum stimulus plateau, and Muscle strength [mean (SD)] (kg)
3-s descent ramp), and rest periods of 50 s for every 10 Quadriceps strength 10.42 (2.82) 13.36 (2.95) 0.001
consecutive wave trains. Current was applied at a max- Tibialis anterior strength 4.12 (1.69) 5.80 (2.01) 0.001
Balance test
imum tolerable level (Kramer, 1982). Tinetti test score 19.56 (4.60) 23.88 (3.28) 0.001
[mean (SD)]
Tinetti test classification [n (%)]
Statistical analysis High risk of falling 10 (40) 2 (8) 0.004
We reported demographic and clinical variables using Risk of falling 11 (44) 12 (48)
descriptive statistics: mean ± SD and proportions for Without risk of falling
Berg test score
4 (16)
36.76 (5.98)
11
40.36
(44)
(5.46) 0.001
dichotomous or nominal variables. The paired-sample [mean (SD)]
t-test and the χ2-test were used to compare continuous Berg test classification [n (%)]
Medium fall risk 18 (72) 11 (44) 0.001
and categorical variables. Pearson’s products correlation Low fall risk 7 (28) 14 (56)
was used to determine associations between the changes Mobility test
in the strength and the changes in the balance and 6 min walk test 336.8 (72.91) 402.8 (81.3) 0.001
[mean (SD)] (m)
mobility between before and after the intervention. We Get up and go test 13.72 (2.71) 10.24 (2.15) 0.001
used the statistical package SPSS version 20 for Mac [mean (SD)] (s)
Get up and go test classification [n (%)]
(IBM Corp., Chicago, Illinois, USA) and statistical sig- Mostly independent 21 (84) 10 (40) 0.075
nificance was considered to be reached at a P value of less to mobility
than 0.05 (two-sided). Independent to 4 (16) 15 (60)
mobility

Results
We included 25 individuals with falls syndrome: 96%
women, with a mean age of 65.2 ± 5.5 years, 48% having
attended elementary school, and with a mean BMI of
28.13 ± 3.22 kg/m2. All patients had experienced at least
one fall before their recruitment (median = 1, range: 1–4).
The most frequent fall incident was the stumble (80%).
Only 8% of the individuals did not have comorbidities;
16% had diabetes mellitus, 36% had hypertension, 20%
had hypothyroidism, 32% had osteoarthritis, 12% suf-
fered from heart diseases, and 20% had dyslipidemia.
The individuals received 35.6 ± 0.76 intervention ses-
sions. We found no complications among the individuals
who received the treatment.
Muscle strength and clinical evaluation
We examined the relation between strength (the quad-
riceps and tibialis anterior muscles) and function (Tinetti
test, Berg test, GUGT, and 6-min walk test). The results
showed a slight correlation between the quadriceps
muscle strength and the Berg test score (r = 0.472;
P = 0.017) and the 6-min walk test distance (r = 0.505;
P = 0.01) and between the tibialis anterior muscle
strength and the Berg test score (r = 0.589; P = 0.002), the
6-min walk test distance (r = 0.655; P = 0.001), and the
GUGT (r = − 0.400; P = 0.048).

Main outcomes Discussion

After the intervention, the participants had improved
strength in the quadriceps (10.42 ± 2.82 vs. 13.63 ±
2.45 kg, P = 0.001) and the tibialis anterior (4.12 ± 1.69 vs.
5.80 ± 2.01 kg, P = 0.001). The participants also showed
significant improvements on other clinical tests (Berg,
Tinetti, and GUGT; Table 1).
Risk of falling according to clinical evaluations
At the baseline evaluation, only 16% of the individuals
were without risk of falling as determined by the Tinetti
test; 28% were at low risk of falling according to the Berg
test, and 16% were categorized as ‘independent to
mobility’ according to the GUGT. After the intervention,
we found that 44% of the participants were without risk
of falling according to the Tinetti test, 44% were at low
risk of falling according to the Berg test, and 60% were
‘independent to mobility’ according to the GUGT
(Table 1).
Strengthening programs have proven to be an effective
intervention for reducing the risk of falling in older people
(Clemson et al., 2010; Sherrington et al., 2011; Prata and
Scheicher, 2015). These programs include different mod-
alities of exercises (strength, balance, endurance, flexibility,
and walking) (Sherrington et al., 2008); however, we eval-
uated Russian stimulation plus isometric exercise for
improving strength, balance, and mobility with the purpose
of decreasing the risk of falling.
After the intervention, the participants showed improved
muscle strength (quadriceps and tiabilis anterior) and
improved balance, as evaluated by the Berg balance test.
Moreover, the participants had a decreased risk of falling
as they achieved better scores in the Tinetti test. Also,
they improved their mobility, as indicated by better
performances in the GUGT and the 6-min walking test.
These results reflect that a specific (strengthening)
intervention can clearly improve strength and function in

Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.

44 International Journal of Rehabilitation Research 2019, Vol 42 No 1
old individuals with mobility disability (Protas and
Tissier, 2009).
Exercise intervention has shown positive effects on
clinical and functional evaluations (including the GUGT,
the walking speed, and the Tinetti and Berg tests) in
older individuals (Howe et al., 2011). In our case, we used
two interventions: Russian stimulation (previously used
only in healthy individuals and athletes) (Ward and
Shkuratova, 2002) and isometric exercise, to improve
muscle strength. The effects of these interventions were
reflected in our clinical evaluations too. It has been
shown that a specific resistance training program may
improve balance in older individuals (Pamukoff et al.,
2014). This program improved the participants’ perfor-
mance on the walking speed test, with more meters
covered per second and a greater total distance. Specific
intervention (strengthening and speed training) can
clearly improve function and strength in seniors with
mobility disability (Protas and Tissier, 2009).
This study has some minor shortcomings, which deserve
to be highlighted. We did not include a control group
(without Russian stimulation); thus, we cannot conclude
with certainty that the improvement was directly related
to electrical stimulation. However, the relationship
between electrical stimulation and strength improvement
has been proven in other participant groups (Lake 1992;
Ward and Shkuratova, 2002). Furthermore, the observed
changes in muscle strength, balance, and mobility may
decrease the fall risk, but this needs to be studied further.
In addition, We did not examine individual oldest old age
range. Rather, our patients were younger than 70 years of
age, and therefore, this is might be a factor favoring the
improvement in muscle strength as the risk of falling and
fall-related injury is known to increase with age
(Grundstrom et al., 2012; LaRoche et al., 2014). Finally, a
higher number of participants, with greater comorbidity
(another possible factor that increases the risk of falls),
could confirm the positive effects of our treatment pro-
gram on a larger population, and we will need to follow
up on the participants to verify that they do not indeed
suffer falls (Gale et al., 2016).
Conclusion
Russian stimulation plus isometric exercise improves
strength, balance, and mobility in older people and may
reduce the risk for falls; the latter needs to be studied
further.
Acknowledgements
The authors thank the entire rehabilitation and geriatric
team, and we thank the patients at Hospital General de
México.
Conflicts of interest
There are no conflicts of interest.
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
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