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Falls and Frailty – Better balance

Evidence summary (Updated 2022)
A systematic review identified eleven trials investigating the effects of exercise interventions on gait ability in those with frailty. Six studies revealed improvements in gait after the physical training period, whereas five studies demonstrated no improvement. Three of the studies that demonstrated improvements used multi-component exercise programs, two studies used only resistance exercises, and one study used endurance training combined with yoga. The mean improvement in gait ranged from 4% to 50% [1 ].

Ten studies investigated the effects of exercise interventions on balance. Eight of the investigations revealed enhanced balance after the physical training period, whereas two studies did not demonstrate any improvement. Seven of the studies with balance improvements used multi-component exercise programs that included balance training, and one study included Tai Chi exercises. The mean improvement in balance ranged from 5% to 80% [1].

Thirteen studies investigated the effects of exercise interventions on lower-body muscle strength. Nine studies revealed increased muscle strength after the physical training period, whereas four studies did not identify any improvement. Five of the studies that demonstrated enhanced strength used resistance exercise programs, and four studies used multi-component exercise interventions. The mean increase in strength ranged from 6% to 60% [1]

A meta-analysis found no effects upon gait speed (n= 3 studies, SMD -0.06 (CI -0.49 to 0.37), moderate heterogeneity) or timed up and go speed (n = 2 studies, SMD 0.57 (CI -0.01 to 1.16), low heterogeneity), but significant differences in muscle strength (n = 4, SMD 0.44 (CI 0.11 to 0.77)), moderate heterogeneity) and balance (n = 3 studies, SMD 0.33 (CI 0.08 to 0.57), low heterogeneity)) were observed. Included studies were generally small and low quality, with short follow-ups and focused on observed physical functioning outcomes [2].

More recent evidence has shown that focus on balance contributes to significant reduction in fallers in nursing home residents > 80yrs [3]. In particular a large systematic review (involving 30697 people >= 65 years) felt the largest reduction in fallers involved the following components: anticipatory control, dynamic stability, functional stability limits,, reactive control and flexibility – the first 4 being balance related [4]. The benefit is greater if the intervention is sustained for longer and is frequent [5].

A study in healthy adults over 65 showed exercise improved balance and confidence in balance which in turn reduced number of fallers and falls [6]

Additionally, a study in frail community dwelling adults > 65yrs showed exercise interventions improved knee extension strength, walking speed, timed up-and-go test (TUG), semi-tandem balance, Berg balance scale (BBS), Short Physical Performance Battery (SPPB), Physical Performance Test (PPT) and ADLs [7].
Although a small study Thomas et al found many activities improved balance and advise ‘Physical inactivity should be avoided’ [8]

A further systematic review found that balance should be checked in all adults having hip surgery and balance training included in post-operative rehabilitation plans as this improved overall physical functioning [9]

Pilates improves static, dynamic and overall balance and outperforms other balance/falls-related interventions but effect on falls is unclear due to lack of studies [10]

Quality of evidence
B – large number of studies with large numbers but with heterogeneity in the studies.

Strength of recommendation
1 – strong

Balance exercises should be part of falls prevention whether in the community or nursing homes, in groups may be more beneficial. Starting slowly and building gradually increasing complexity but maintaining a training stimulus in the form of volume, intensity and complexity over time will be most effective. Balance should be evaluated for anyone undergoing hip surgery and balance exercises included in the postoperative plan to reduce the risk of falls.

[1] Cadore EL, Rodríguez-Mañas L, Sinclair A, Izquierdo M. Effects of different exercise interventions on risk of falls, gait ability, and balance in physically frail older adults: a systematic review. Rejuvenation research. 2013 Apr 1;16(2):105-14.
[2] Frost R, Belk C, Jovicic A, Ricciardi F, Kharicha K, Gardner B, Iliffe S, Goodman C, Manthorpe J, Drennan VM, Walters K. Health promotion interventions for community-dwelling older people with mild or pre-frailty: a systematic review and meta-analysis. BMC geriatrics. 2017 Dec;17(1):157.
[3] Wang et al. 2020 Effectiveness of exercise intervention on fall-related fractures in older adults: a systematic review and meta-analysis of randomized controlled trials. BMC Geriatrics. 2020 Sep 4;20(1):322. doi: 10.1186/s12877-020-01721-6.
[4]. Sibley KM, Thomas SM, Veroniki AA, Rodrigues M, Hamid JS, Lachance CC, Cogo E, Khan PA, Riva JJ, Thavorn K, MacDonald H, Holroyd-Leduc J, Feldman F, Kerr GD, Jaglal SB, Straus SE, Tricco AC. Comparative effectiveness of exercise interventions for preventing falls in older adults: A secondary analysis of a systematic review with network meta-analysis. Exp Gerontol. 2021 Jan;143:111151. doi: 10.1016/j.exger.2020.111151. Epub 2020 Nov 10. PMID: 33186739.

[5] Sun M, Min L, Xu N, Huang L, Li X. The Effect of Exercise Intervention on Reducing the Fall Risk in Older Adults: A Meta-Analysis of Randomized Controlled Trials. Int J Environ Res Public Health. 2021 Nov 29;18(23):12562. doi: 10.3390/ijerph182312562. PMID: 34886293; PMCID: PMC8657315.

[6] Papalia GF, Papalia R, Diaz Balzani LA, Torre G, Zampogna B, Vasta S, Fossati C, Alifano AM, Denaro V. The Effects of Physical Exercise on Balance and Prevention of Falls in Older People: A Systematic Review and Meta-Analysis. J Clin Med. 2020 Aug 11;9(8):2595. doi: 10.3390/jcm9082595. PMID: 32796528; PMCID: PMC7466089.

[7] Zhang Y, Zhang Y, Du S, Wang Q, Xia H, Sun R. Exercise interventions for improving physical function, daily living activities and quality of life in community-dwelling frail older adults: A systematic review and meta-analysis of randomized controlled trials. Geriatr Nurs. 2020 May-Jun;41(3):261-273. doi: 10.1016/j.gerinurse.2019.10.006. Epub 2019 Nov 6. PMID: 31706592.

[8] Thomas E and Battaglia G and Patti A and Brusa J and Leonardi V and Palma A and Bellafiore M. 2019 Physical activity programs for balance and fall prevention in elderly: A systematic review. Medicine 2019 Jul;98(27):e16218.
doi: 10.1097/MD.0000000000016218.

[9] Lee SY, Jung SH, Lee SU, Ha YC, Lim JY. Effect of Balance Training After Hip Fracture Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Studies. J Gerontol A Biol Sci Med Sci. 2019 Sep 15;74(10):1679-1685. doi: 10.1093/gerona/gly271. PMID: 30517613.

[10] Moreno-Segura N, Igual-Camacho C, Ballester-Gil Y, Blasco-Igual MC, Blasco JM. The Effects of the Pilates Training Method on Balance and Falls of Older Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Aging Phys Act. 2018 Apr 1;26(2):327-344. doi: 10.1123/japa.2017-0078. Epub 2018 Apr 12. PMID: 28771109.