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Falls and Frailty – Improves functional ability

Evidence summary (Updated 2022)
Exercise showed positive results in reducing ADL disability in around 40% of studies. In the 10 studies that used basic ADL scales 50% showed positive effects, in the four studies that used instrumental ADL (IADL) scales only one improved IADL ability, and in the six studies that used both subscales only two reported significant improvements [1].
Twelve months of high-intensity weight-lifting exercise and targeted multidisciplinary interventions results in reduced use of assistive devices for mobility, function, and safety compared with controls. Resistance training results in significantly less decline in basic ADL toileting and transferring scores compared to controls, with a similar trend for overall basic ADL score. IADL scores do not change differentially between groups over time [2].
Overall, group exercise interventions have a significant and beneficial effect on physical functioning immediately post-intervention compared to usual care or flexibility home control exercise programmes. However the benefits are lost within 12 weeks, once exercise ceases. Significant improvements are seen 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) only [3].

Recent review of the literature provided a number of large systematic reviews and metanalyses:

A systematic review showed significant improvements following exercise interventions in: handgrip (SMD 0.51, p = 0.001) and lower-limb strength (SMD 0.93, p < 0.001), agility (SMD 0.78, p = 0.003), gait speed (SMD 0.75, p < 0.001), postural stability (SMD 0.68, p = 0.007), functional performance (SMD 0.76, p < 0.001), fat mass (SMD 0.29, p = 0.001), and muscle mass (SMD 0.29, p = 0.002). This was true for both early and late stages of sarcopenia and frailty [4].

Resistance training (RT) has shown significant improvements in: femoral neck BMD; health-related QoL; physical functioning; and pain in over 50s at risk of or history of fragility fracture. Effects on falls and falls-related fractures not clear [5]. Impact exercises may improve physical functioning (timed up-and-go) and disability, and BMD at the lumbar spine and femoral neck, but the certainty of this evidence is low [6]

Eccentric RT was as effective as conventional RT in reducing falls incidence and improving functional performance. [7]

Pilates is better than no intervention (control) for: mediolateral balance (SMD −1.77, CI −2.84 to −0.70, p = 0.001), mobility (SMD 9.23, CI 5.74 to 12.73, p < 0.00001) and fear of falling (SMD −8.61, CI −10.16 to −7.07, p < 0.00001). Pilates outperformed other exercise types in: functional mobility (SMD −1.21, CI −2.30 to −0.11, p = 0.03) and mobility (SMD 3.25, CI 1.46 to 5.04, p < 0.0004) [5]

Eccentric RT was as effective as conventional RT in reducing falls incidence and improving functional performance. [8]

A large SR (28523 people > 65) into long term exercise interventions no difference in dropout (RR = 1.05, CI 0.95–1.17) or mortality rates (RR = 0.93, CI 0.83–1.04) between exercise and control groups. Exercise reduced mortality rate among clinical populations (RR = 0.67, CI 0.48–0.95). Exercise significantly reduced number of falls and fall-associated injuries, and improved physical function and cognition [9].

Multi-component exercise interventions can currently be recommended for pre-frail and frail older adults to improve muscular strength, gait speed, balance and physical performance, including resistance, aerobic, balance and flexibility tasks. RT (alone) was also suggested to be beneficial, in particular for improving muscular strength, gait speed and physical performance, and should be considered as part of a multi-component exercise intervention. Other types of exercise were not sufficiently studied and their effectiveness is yet to be established. Exercise combined with nutritional interventions was also comparatively little studied and results were mixed [10].

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

Strength of recommendation
1

Conclusion
Exercise seems to benefit the oldest-old most as well as those in long-term care facilities. It is more effective in the earlier stages of frailty. Longer interventions (>5 months) produce greater gains than shorter ones. Multi-component exercise interventions can currently be recommended for pre-frail and frail older adults to improve muscular strength, gait speed, balance and physical performance, including resistance, aerobic, balance and flexibility tasks, three times per week are most likely to be effective. There is no evidence to suggest exercise is harmful in frail populations.

References
[1] Theou O, Stathokostas L, Roland KP, Jakobi JM, Patterson C, Vandervoort AA, Jones GR. The effectiveness of exercise interventions for the management of frailty: a systematic review. Journal of aging research. 2011.
[2] Singh NA, Quine S, Clemson LM, Williams EJ, Williamson DA, Stavrinos TM, Grady JN, Perry TJ, Lloyd BD, Smith EU, Singh MA. Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: a randomized controlled trial. Journal of the American Medical Directors Association. 2012 Jan 1;13(1):24-30.
[3] 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.
[4] Talar K, Hernández-Belmonte A, Vetrovsky T, Steffl M, Kałamacka E, Courel-Ibáñez J. Benefits of Resistance Training in Early and Late Stages of Frailty and Sarcopenia: A Systematic Review and Meta-Analysis of Randomized Controlled Studies. J Clin Med. 2021 Apr 12;10(8):1630. doi: 10.3390/jcm10081630. PMID: 33921356; PMCID: PMC8070531.

[5] Ponzano M, Rodrigues IB, Hosseini Z, Ashe MC, Butt DA, Chilibeck PD, Stapleton J, Thabane L, Wark JD, Giangregorio LM. Progressive Resistance Training for Improving Health-Related Outcomes in People at Risk of Fracture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Phys Ther. 2021 Feb 4;101(2):pzaa221. doi: 10.1093/ptj/pzaa221. PMID: 33367736.

[6] Rodrigues IB, Ponzano M, Hosseini Z, Thabane L, Chilibeck PD, Butt DA, Ashe MC, Stapleton J, Wark J, Giangregorio LM. The Effect of Impact Exercise (Alone or Multicomponent Intervention) on Health-Related Outcomes in Individuals at Risk of Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Sports Med. 2021 Jun;51(6):1273-1292. doi: 10.1007/s40279-021-01432-x. Epub 2021 Apr 29. PMID: 33914282.

[7] Kulkarni D, Gregory S, Evans M. Effectiveness of eccentric-biased exercise interventions in reducing the incidence of falls and improving functional performance in older adults: a systematic review. Eur Geriatr Med. 2021 Oct 11:1–14. doi: 10.1007/s41999-021-00571-8. Epub ahead of print. PMID: 34633637; PMCID: PMC8503729.

[8] da Silva LD, Shiel A, McIntosh C. Pilates Reducing Falls Risk Factors in Healthy Older Adults: A Systematic Review and Meta-Analysis. Front Med (Lausanne). 2021 Sep 1;8:708883. doi: 10.3389/fmed.2021.708883. PMID: 34540865; PMCID: PMC8440877.Kulkarni D, Gregory S, Evans M. Effectiveness of eccentric-biased exercise interventions in reducing the incidence of falls and improving functional performance in older adults: a systematic review. Eur Geriatr Med. 2021 Oct 11:1–14. doi: 10.1007/s41999-021-00571-8. Epub ahead of print. PMID: 34633637; PMCID: PMC8503729.

[9] García-Hermoso A, Ramirez-Vélez R, Sáez de Asteasu ML, Martínez-Velilla N, Zambom-Ferraresi F, Valenzuela PL, Lucia A, Izquierdo M. Safety and Effectiveness of Long-Term Exercise Interventions in Older Adults: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Sports Med. 2020 Jun;50(6):1095-1106. doi: 10.1007/s40279-020-01259-y. PMID: 32020543.

[10] Jadczak AD, Makwana N, Luscombe-Marsh N, Visvanathan R, Schultz TJ. Effectiveness of exercise interventions on physical function in community-dwelling frail older people: an umbrella review of systematic reviews. JBI Database System Rev Implement Rep. 2018 Mar;16(3):752-775. doi: 10.11124/JBISRIR-2017-003551. PMID: 29521871.