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a Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Sepulveda, California
b Department of Physical Therapy, California State University, Fresno
c Department of Kinesiology, California State University, Northridge
d Ralph H. Johnson VA Medical Center, Charleston, South Carolina
Laurence Z. Rubenstein, Geriatric Research Education and Clinical Center (11E), VA Greater Los Angeles Healthcare System, 16111 Plummer St., Sepulveda, CA 91343 E-mail: lzrubens{at}ucla.edu.
Decision Editor: John E. Morley, MB, BCh
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Abstract |
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Methods. Fifty-nine community-living men 
with specific fall risk factors (i.e., leg weakness, impaired gait or balance, previous falls) were randomly assigned to a control group 
or to a 12-week group exercise program 
. Exercise sessions (90 minutes, three times per week) focused on increasing strength and endurance and improving mobility and balance. Outcome measures included isokinetic strength and endurance, five physical performance measures, and self-reported physical functioning, health perception, activity level, and falls.
Results. Exercisers showed significant improvement in measures of endurance and gait. Isokinetic endurance increased 21% for right knee flexion and 26% for extension. Exercisers had a 10% increase ( p < .05) in distance walked in six minutes, and improved ( p < .05) scores on an observational gait scale. Isokinetic strength improved only for right knee flexion. Exercise achieved no significant effect on hip or ankle strength, balance, self-reported physical functioning, or number of falls. Activity level increased within the exercise group. When fall rates were adjusted for activity level, the exercisers had a lower 3-month fall rate than controls (6 falls/1000 hours of activity vs 16.2 falls/1000 hours, p < .05).
Discussion. These findings suggest that exercise can improve endurance, strength, gait, and function in chronically impaired, fall-prone elderly persons. In addition, increased physical activity was associated with reduced fall rates when adjusted for level of activity.
THERE are encouraging data that exercise programs can improve strength (1)(2)(3)(4)(5), gait (2)(6)(7), balance (1)(8), and perhaps decrease falls (9)(10)(11)(12)(13)(14) among healthy, nonimpaired older adults. However, individuals most at risk for falls—those with gait impairments, weakness, chronic musculoskeletal or neurologic impairments—have been excluded from most exercise studies. Consequently, there is little evidence about the benefits and risks of including individuals at highest risk for falls in structured group exercise.
We conducted a randomized controlled trial to measure effects of an exercise intervention on muscle strength, gait, balance, and endurance among elderly men with risk factors for falls. Secondary aims were to measure effects of exercise on actual fall rates, self-reported health measures, and activity levels.
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Methods |
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4/5 in 
1 leg flexor or extensor muscle); impaired gait (score <10/12 on the gait subscale of the Performance Oriented Mobility Index [POMI]) (15); impaired balance (score <14/16 on the POMI balance subscale); or >1 fall in the previous 6 months (not resulting from a violent blow, loss of consciousness, paralysis, or seizure) (16). Individuals were excluded if they exercised regularly or had severe cardiac or pulmonary disease, a terminal illness, severe joint pain, dementia, medically unresponsive depression, or progressive neurologic disease (e.g., Parkinson's disease).
The subject recruitment process is described in Fig. 1. Participants were randomized using a randomly generated sequence of cards in sealed envelopes. Groups of 16–20 men were randomized together at 3–6-month intervals to ensure exercise groups of manageable size. The research protocol was approved by the institutional review board, and informed consent was obtained from each participant.
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Physical performance tests used to assess strength, endurance, gait, and balance included a sit-to-stand test (19), a 6-minute walk test (20), an indoor obstacle course (21), the POMI (15), and a 15-second one-leg standing balance test. A physical therapist (PT) masked to subject assignment rated videotaped performance on the obstacle course and the POMI. Inter-rater reliability with a physician on a sample of subjects 
was 0.96 ( p < .001, weighted Kappa).
Three subscales of the RAND 36-item Health Survey (SF-36) (22) were used to measure physical functioning, role limitations, and general health perceptions. Physical activity was measured with the Yale Physical Activity Survey (23). Number of falls and injuries sustained during the 12-week intervention period were obtained by questioning participants every 2 weeks either by telephone (controls) or at the exercise classes.
Repeated measures two-way analysis of variance (ANOVA) was performed on outcome variables. Significant interactions were examined (Tukey's test) to determine if effects were greater in the exercise or control group. Difference in fall rates was tested using a z test based on Poisson distribution.
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Results |
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, which increased significantly more for exercisers. Borderline interactions were observed for right knee extension and right hip flexion.
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Exercisers showed greater improvement than controls in the gait and endurance measures (Table 4 ). For the 6-minute walk, exercisers increased the distance they walked an average of 48 meters compared to 12 meters for controls 
. Likewise, the POMI gait score improved significantly more for exercisers than for controls 
. For the sit-to-stand test, exercise subjects increased their average number of repetitions by 23% compared to 4% for controls 
. There were no significant group differences for the obstacle course score, the POMI balance scale, or the one-leg balance test.
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than controls, but there were no differences between groups on the three subscales of the SF-36. Within the exercise group, total activity time per week, as measured by the Yale survey, increased 
, largely reflecting the time spent in the exercise classes (4.5 hours/week). No change in weekly activity time was observed for controls.
During the 3-month intervention period, 38.7% of exercisers and 32.1% of controls reported falling, with a total of 13 and 14 falls, respectively. There were no serious fall-related injuries in either group. To determine whether greater activity levels were associated with an increased risk of falling, we calculated number of falls per 1000 hours of activity. For this calculation we used only the time reported for exercise and recreation activities, because these categories accounted for most nonsedentary activities. Using the combined totals for these two categories, total hours of activity during the 12-week intervention was 2141.23 hours for the exercise group and 861.60 hours for controls. The fall rate per 1000 hours of activity was 6.0 falls for the exercise group compared to 16.2 falls for the control group 
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Discussion |
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The most notable physical benefit associated with this short-term exercise program appears to be an overall improvement in physical endurance, as evidenced by significant increases in both isokinetic and functional measures. The increase in muscle endurance, as measured by isokinetic total work, has not been reported previously. The fact that exercisers were able to increase their walking distance an average of 48 meters in just 12 weeks further substantiates the improvements we saw in muscle endurance and gait characteristics.
These are clinically important findings for an impaired population such as ours, because even modest improvements in endurance, strength, and mobility can have major impacts on an individual's ability to remain independent in the community. Previous research has shown that exercise has a positive impact on physical performance in both independent (5) and functionally impaired (4) community-dwelling older persons.
Exercise did not reduce unadjusted 3-month fall rates in this sample of fall-prone elderly men, which is not surprising given our short follow-up period. Other intervention studies have demonstrated significantly reduced fall rates only after one year of follow-up (9)(13). In addition, our participants had multiple risk factors for falling, which makes it more difficult to demonstrate a positive impact from a single intervention alone (24). Two recent studies (12)(13) used a multifactorial approach to address multiple fall risk factors and successfully reduced one-year fall rates in community-living older adults.
The fact that the rate of falls per unit of activity was significantly lower in the exercise group is a new and interesting finding. Exercise clearly benefits many aspects of health and quality of life, as is well documented in the rapidly growing exercise research literature. However, for individuals who are already fall-prone, increased activity may result in a greater risk of falling due to increased exposure to environmental hazards (25)(26). It is possible that a potential reduction in falls from reduced risk factors would be offset by increased physical activity and exposure to risk, with no net change in overall fall frequency. Our attempt to adjust for exposure is one strategy for dealing with this offsetting phenomenon. Our findings suggest that simply looking at unadjusted fall rates may underestimate positive effects of exercise for fall-prone individuals.
A relatively small sample size and short follow-up period limited our study power, and our results should be generalized primarily to similar fall-prone, male populations. Nonetheless, these findings provide new evidence that older individuals with chronic impairments and risk factors for falls can safely participate in structured group exercise, and achieve improvements in endurance, strength, gait, and function.
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Acknowledgments |
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The authors thank Roi Ann Wallis, MD, Ernie Sacco, MS, Alane Pollan, MS, Shandon Hunter, MS, Karen Linderborn, RN, MSN, Lisa Davis, Ty Lam, and Jan Hayes for their assistance with this project.
Received February 14, 2000
Accepted February 22, 2000
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| Journals of Gerontology Series B: Psychological Sciences and Social Sciences | |
The physical examination was conducted by a physician assistant and physical therapist and included: quantitative neurologic assessment; postural pulse and blood pressure measurements; manual muscle and range of motion testing; foot evaluation; observational gait analysis (
Of subjects not eligible after the physical examination, 113 (41%) had no risk factors, 88 (32%) were too ill, and 17 (6%) refused to be randomized.