Fall Prevention Exercises for Seniors
In this second part of our work on choosing the right fall prevention program, we look at different options for the fall prevention exercises component of a fall prevention program, and how to decide which exercises for seniors program would work best for a specific older adult.
There are two components to discuss:
A. an initial exercise intervention designed to improve to a certain baseline level those physical attributes that affect fall risk (balance, gait, strength and flexibility), and (ideally) prepare you for an ongoing "exercise for seniors" type of program; and
B. an ongoing "exercises for seniors" program that you take part in indefinitely, and which is designed to maintain and improve the physical attributes that relate to falls.
Different exercises for different fall risks
Whether you need both of the exercise components, or just the ongoing "exercise for seniors" component, and exactly what type of fall prevention exercises are right for you, really comes down to your specific physical condition and your fall risk. Here is a useful table that focuses on the right sort of exercise for different types of people, from a paper by Dr. Rose of California State University, Fullerton (1).
There are some important takeaways from the table above.
"Low fall risk" individuals need an ongoing exercise program of the right sort, but there is no real need in their case for an initial exercise intervention as they are likely already at a level to start an ongoing exercises for seniors program.
Moderate risk and High risk individuals need some sort of initial personalized assessment to decide just what level of physical capability they have today, followed by a targeted, initial exercise intervention to improve specific physical characteristics to a baseline level.
For moderate risk and high risk people, Dr. Rose recommends a behavioral component (what we have been calling the behavior change component) as being important in addition to exercise.
Ongoing exercises for seniors program to reduce fall risk
Below are suggested examples of ongoing exercise programs for reducing fall risk.
An obvious place to start the discussion is Tai Chi. This is a widely available program with a number of attractive attributes.
- It has been shown in studies described in the CDC fall prevention compendium to have significantly reduced fall incidence.
- It is one of the rare programs on that list that is ongoing and can be taken for an indefinite period. This is important as research (2) strongly suggests that you need a minimum of 50 hours of training over a six month period to positively impact balance ability, which is in turn an important component of fall risk.
- By its nature, Tai Chi provides graduated difficulty, so that as one advances the exercise routines become more challenging. This is important because research (2) suggests that balance improvement requires an exercise regimen that continually challenges one's balance skills.
- Classes are readily available all around the USA, and include beginner level classes as well as more advanced classes.
General exercise programs
We have not found other, equally well credentialed programs for long term fall prevention exercises. If you want a group exercise program for ongoing fall risk reduction, and you don't want Tai Chi, then the guidelines for selection are not very precise.
In the table above, Dr. Rose mentions walking, group exercise of various sorts, and recreational activities with strong balance components. At the bottom of this article we have sections on what to look for in a group exercise program, and on instructor credentials. Use that material to help pick the best group exercise program.
Places to start a search for what might be available in your city include:
- The YMCA, which has a variety of programs for older adult group exercise;
- Silver Sneakers, which is a group exercise program targeted at older adults and with fairly wide availability in North America;
- Your local senior center;
- This list of exercise programs for seniors (NOT specifically for fall risk reduction) from the NCOA; and
- Exercise programs for people with arthritis (Arthritis Foundation).
Initial exercise intervention
Medium and high risk individuals, after a suitable physical assessment by a professional, will most likely need some type of initial exercise intervention to improve the physical attributes most likely to lead to falls in their specific situation. The multi-factorial programs described in part 1 of this article typically include an initial exercise intervention. But there are various alternatives as well, both for exercise at home, and for group exercise.
Do it Yourself (DIY) at home
Graduates of the multi-factorial fall prevention programs will typically come away with lists of exercises they can do at home to continue the process of working on balance, and other relevant physical traits. Other sources of relevant home exercises are:
- NIH Senior Health: Balance Exercises
- National Institute on Aging Exercise Guide (includes balance exercise)
- National Institute on Aging Go4Life Exercises
- Exercises and a DVD excerpted from the FallProof program (see below)
Otago Method: Supervised, at Home (USA, New Zealand)
For those who need an initial exercise intervention to get them up to a level where they can engage in group exercise programs, a strong, evidence-based alternative is the Otago Method. This method was developed in New Zealand, is on the CDC list and NCOA list of effective fall prevention interventions, and has been "translated" (funded by the CDC) for dissemination and implementation in the USA.
This is an individually tailored program of muscle-strengthening and balance-retraining exercises of increasing difficulty, combined with a walking program.
As implemented in the U.S., the key features of the Otago Exercise Program are:
1. Delivered only by Physical Therapists (PTs) or PT assistants.
2. Provides a minimum of five visits over eight weeks with a follow-up visit at six months.
3. Takes place in the older adult’s home or in an outpatient setting.
4. Encourages the PTs to find ways to help older adults adhere to the program. This may include encouraging the caregiver to exercise with the older adult or having participants perform their Otago exercises in a group setting.
The best place to learn more about the Otago Exercise program in the USA is at the website below, prepared by the University of North Carolina. It is targeted at Physical Therapists that want to teach this methodology, but there are lots of videos and other resources that illustrate the types of exercises and activities that form the program.
View Otago Exercise program resources at UNC website
The UNC website includes a page where you can find a therapist trained in the Otago methodology (in the USA). Unfortunately there are only 10 states on their map that have pins representing PT's in that state. But they include an email to ask about other states, and say that over 1,000 PTs have been trained in this methodology using their online resources, so maybe it is more widespread than it appears.
One path to starting this type of exercise program is to get a physician to write a referral to a PT who is trained in the Otago Method, and has experience working with older adults. The credentials of NCS (neuro-certified specialist) or GCS (geriatric-certified specialist) are valuable indicators of relevant expertise.
FallProofTM: Group exercise (USA)
This is a well regarded, balance and mobility program, developed by Dr. Rose at California State University, Fullerton. It includes individualized assessment at the beginning of the program, a trainer certification program to ensure consistency, and a duration of 24 weeks which is unusually long for a program of this type, but which recent research (2) strongly suggests is superior to a shorter program.
The FallProof program website (containing lots of useful additional background) describes this as an evidence-based program, although it is not included in the CDC falls compendium, nor on the NCOA list of "proven programs".
You can download a list of classes and trainers from this page on the FallProof website.
Erlangen Fitness Intervention: Group exercise (Germany)
This is one of the single intervention studies that was included in the CDC Falls Compendium, and it has been turned into a community-available program in Germany. The website that contains information about training and manuals and the like is here. (Note: website is in German).
Postural Stability: Group exercise (UK)
Also on the CDC Falls Compendium list, this program is based on the Falls Management Exercise (FAME) Intervention. The original research was done in the UK (London), and it examined the effectiveness of an individualized, tailored group and home-based exercise intervention designed to improve participants’ dynamic balance and core and leg strength, and to recover their ability to get down to and up from the floor.
This program is delivered by certified "Postural Stability Instructors". This website contains information on training to be an instructor, and some limited information on how to find such an instructor.
What to look for in Group Exercise
There are other group exercise programs one can find that focus specifically on fall prevention, either in the form of an initial intervention or as an ongoing program. These programs are typically not based on specific studies and don't necessarily count as "evidence-based". However sometimes they may be the most suitable alternative, especially if they are specifically tailored to your particular needs. One typically finds one of these fall prevention programs at a local senior center or health facility. A good example is the Always Active Program (San Francisco), which has both a conventional older adult exercise program and a more specialized Fall Prevention Program.
It gets tricky to evaluate the quality of a group exercise program that is not evidence-based if you are not an expert however. We think the two areas to look at are the content and design of the program, and the credentials and background of the people who designed the program and who teach it.
Content of the class
One important thing to note is that a fall prevention exercise class is not at all the same as a general exercise class for older adults. A fall prevention class will be carefully designed to improve (dynamic) balance, gait, strength, and flexibility.
For fall prevention, cardio-vascular exercise is less relevant (although of course it has many other health benefits, and may well have secondary effects that reduce fall risk) (6). And the widely available, aqua-fitness classes, while good for many aspects of fitness, are not the right approach if one is seeking fall prevention, because a good balance training program really needs to take place in a land environment where the body's balance mechanisms are fully employed.
In the ideal world, a group exercise, fall prevention program will include some way in which it is personalized — so that different people can take the exercises at differing levels, so they are always challenged but never over-taxed.
One thing to bear in mind is that a meta-analysis of recent research (2) concluded that to improve balance, you needed a total of 50 hours balance training over a six month period (2 hours per week for example). So how often you exercise, and for how long, are both important.
Exercise trainer credentials
Once you find a program that claims to have been designed with fall prevention in mind and which seems to have the right content, the next step in evaluating it is to look at the training and credentials of the trainer. The guidelines here are also not very straightforward, unfortunately.
One important thing to look for is that the designer of the program, and the trainers, have extensive prior experience working with older adults. One does NOT want a newly minted exercise trainer who only has experience training 20 year olds!
There are also various credentials that a trainer may have. None are terribly specific to older adults or fall prevention unfortunately. But some credentialing bodies have more rigorous programs than others.
Dr. Christian Thompson, suggests looking for credentialling by the following organizations in the USA.
- American College of Sports Medicine (ACSM);
- National Strength & Conditioning Association (NSCA);
- American Council on Exercise (ACE).
In Europe, there is PTA Global, and there are likely similar accreditation bodies in other countries.
The Importance of Personalization in Exercise
Notes Dr. Thompson:
"The best results will come from an exercise program which is personalized to match the specific challenges and physical condition of a given individual. This is especially important in older adults, because they are an extremely heterogenous group in terms of level of physical capabilities — far more so than say a group of 25 year olds. So what works for "Ms Average" may not work at all well for those at the extremes of the distribution of physical abilities.
It is important to note that the exercise component within a multifactorial fall prevention program is often quite brief and lacks adaptability (suggestions for progression/regression of the selected exercises). Often this is because the initial research to support the evidence-based programs was performed several years ago, and the researchers are often not trained in physical therapy/kinesiology. This may result in that exercise program being ineffective for a proportion of older adults. So we encourage people to augment the multifactorial programs with a more personalized exercise regimen."
The personalized exercise program might be a group program which can be tailored so that individuals experience slightly different exercise difficulty. Or it might be a truly personalized program, with a well credentialed individual trainer.
For now, this level of individual tailoring may be too expensive for many. But, notes Dr. Thompson, "we are working on ways to develop new, mass personalized approaches that will be both personal and cost effective."
References and Background Reading
1. J. Rehab. Research & Development, 45, 8, 2008, pp 1153-1166, Debra J. Rose.
2. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc. 2008;56:2234–2243.
4. NIH SeniorHealth: Exercises - A set of useful questions about exercise for older adults, with answers and some examples of exercises to try for various purposes.
6. Footnote on cardiovascular exercise and falls from Dr. Renfro: "In actuality, improved cardio fitness can be important in fall prevention, especially in those older adults with chronic diseases such as hypertension and diabetes. Better cardio fitness leads to improved chronic conditions which may result in less medications needed which will decrease fall risk secondarily. Better cardio fitness can also lead to improved circulation which may improve lower extremity sensation and therefore also decrease fall risk secondarily. Certainly it is not as critical as balance, but it could be argued to be as critical as flexibility. However, this is just my conjecture and nothing more."
Lead author: Richard Caro