Review ArticleAbstract
Background: With ageing, older adults are faced with decreasing strength and balance and increasing risk for falls. A fall followed by fracture is a factor in mortality and decreased quality of life in older people. However, few systematic review studies have analyzed the effects of training programs in reducing falls in older people.
Aim: This systematic review study aimed to analyze the effects of physical training programs on the risk of falls in older people.
Methods: We used the PRISMA guidelines in conducting the systematic review. The search for eligible studies was performed using four electronic databases (PubMed, BVS Regional Portal, British Library, and Library of Congress).
Results: The results showed a decrease in the risk of falling in 21 studies. Only four studies did not show a reduction in the risk of falling after a training program.
Conclusion: Combined or multicomponent training programs, as well as isolated strength training, could decrease the risk of falling in older people.
Keywords: Risk of Falling; Older Adults; Training Program; Balance
Core Tip
Regular and systematic physical exercises can contribute in a comprehensive way to the healthy ageing process by helping increase muscle strength, bone mineral density (hip and spine), and static and dynamic balance, ultimately decreasing the risk of falling. However, controversial results have been observed, with some studies indicating no improvement, especially in the risk of falls in older adults. Thus, the characteristics of the different physical exercise programs must be investigated. Research should discern which types of exercise reduce the risk of falling in the older adults. Thus, this systematic review study aimed to analyses the effects of physical training programs on the risk of falls in older adults.
Introduction
The global projection is that by 2050, the number of older
people will increase exponentially, surpassing the number of
children under 14 years old [1]. As people age, changes in muscle
and bone mass can be observed, as well as reduction in the capacity
to produce strength, which impacts the activities of daily living.
Thus, regular physical activities can delay marked physiological
losses. Falls followed by fractures are recurrent among older adults,
attributable to muscle instability and bone fragility [2,3]. Changes
in the sensory and motor systems also become present, and these
cause postural instability, which can increase the risk of falling.
Falls in older people represent a major public health problem,
associated with a worsening quality of life and increased mortality
[4]. In Brazil, about one-third of older adults experience at least
one fall per year, and the more advanced the age, the greater the
risk. Women are affected in greater proportion, as they are more
sensitive to changes inherent to ageing, such as hormonal changes, which increase the incidence of sarcopenia and osteoporosis and
make them more susceptible to falling [5].
Another factor associated with the risk of falling is the level of
dependency of older adults, which can reach up to 14 times that of
those with a high level of independence [6]. Regular and systematic
physical exercises can contribute in a comprehensive way to the
healthy ageing process by helping increase muscle strength, bone
mineral density (hip and spine), and static and dynamic balance,
ultimately decreasing the risk of falling [4,7,8].
However, controversial results have been observed, with some
studies indicating no improvement, especially in the risk of falls
in older adults [9-12]. Thus, the characteristics of the different
physical exercise programs must be investigated. Research should
discern which types of exercise reduce the risk of falling in the older
adults, for example, isolated (strength, aerobic, and balance) or
combined (balance/strength, aerobic/balance/strength, aerobic/
balance, and aerobic/strength). Thus, this systematic review study
aimed to analyses the effects of physical training programs on the
risk of falls in older adults.
Materials and Methods
Search Strategy
For the review study, we adhered to the guidelines for systematic reviews (PRISMA) Moher, et al. [13]. The search for eligible studies was carried out using four electronic databases (PubMed, BVS Regional Portal, British Library, and Library of Congress) until October 2019, without language restrictions. The terms used for the search were as follows: the search strategy combined terms covering the topics of population: (resistance training OR strength training) AND (balance training) AND (older OR elderly OR older adults) AND (risk of falling). The search was carried out using combinations of the following terms linked with Boolean operators “AND” (inter-group Boolean operator) and “OR” (intra-group Boolean operator). Duplicate studies were removed. Three independent researchers analyzed titles and abstracts and then selected the articles relevant to the research.
Eligibility Criteria
Articles that met the following inclusion criteria were selected:
(1) Original study;
(2) Providing a description of the training program;
(3) Having at least one of the following tests as a method of
evaluation: Balance Evaluation System Test, Timed Up and Go
Test, Six Minute Walk Test, Sit To Stand Test, Falls Efficacy Scale- Internacional, Posturografia estática BioRescue, Functional
Reach Test, and Berg Balance Scale;
(4) Randomised clinical trials;
(5) Published in peer-reviewed scientific journals; and
(6) Studies evaluating the effects of training programs on the
risk of falls in older adults.
The exclusion criteria were as follows:
(1) Review articles;
(2) Abstracts of unpublished conference papers and studies;
and
(3) No protocol for assessing balance or risk of falling.
According to the inclusion and exclusion criteria, 19 studies were excluded. The studies were evaluated in their entirety by two reviewers. Disagreements were decided by consensus, and when necessary, with the participation of a third reviewer. Eligible study references were also analyzed to identify other relevant studies.
Data Extraction
Independently, the same two reviewers extracted the following data from each selected study: name of the first author, year of publication, research title, age group (years), balance test, type of exercise used in the training program, weekly frequency of the training program, intensity and duration of the training program, training period in months, completion of the study, and periodicals in which the studies were published.
Evaluation of Methodological Quality of Studies
The quality evaluation of the eligible studies was carried out by two independent reviewers, with doubts resolved by consensus, and with the participation of a third reviewer when no consensus could be reached. The Physiotherapy Evidence Database (PEDro) scale was used to assess randomised clinical trials. The instrument consists of 11 items, the first of which is not computed in the final score. Thus, the scale has a score from 0 to 10 [14].
Results
Study Selection
From the electronic databases (PubMed, BVS Regional Portal, British Library, and Library of Congress), 17727 studies were found. After removing the duplicates, 17610 remained. After the selection based on titles and abstracts, 44 complete articles remained. Of these, 25 were selected and used in the present work, as shown in Figure 1.
Figure 1: Organization of articles reviewing the effects of training programs on the risk of falls in the elderly. PRISMA 2009 flow diagram. Adapted from Moher, et al. [13].
Study Characteristics
Table 1 presents the general characteristics and results of studies that analyzed the effects of training programs on the risk of falls in older adults. The analyzed studies were published between 2008 and 2019, including a total of 2229 people. The studies were conducted in Australia [15], Brazil [4,10,16-18], Canada [19], China [20], Finland [21], Germany [22], Hungary [23], India [24], Iran [25], Japan [11], Portugal [7,26], Republic of Korea [27], Spain [12,28], Switzerland [29], and the United States [9,30-33]. Eight studies were identified as using a combination of balance and strength exercises [4,16,17,19,21,22,24,29]; three studies using a combination of aerobic exercises, balance, and strength [7,9,28]; six studies using strength exercises [15,20,25,27,30,33]; one study using a combination of aerobic and strength exercises [10]; one study using aerobic exercises [12]; four studies using balance exercises [11,23,31,32]; and two studies using balance and strength exercises separately [18,26]. A reduction in the risk of falling was observed in 21 studies [4,7,15-33]. In four studies, training programs did not show a reduction in the risk of falling [9-12]. To evaluate the risk of falling in the older population, 16 studies used the Timed Up and Go Test [4,7,9,11,12,15-22,25,26,29]. Some studies opted for other tests to assess the risk of falling, such as the Balance Evaluation System Test [28], Six Minute Walk Test [30,33], Sit-to-Stand [10], Falls Efficacy Scale-Internacional [31], Posturografia estática BioRescue [27], Functional Reach Test [24], and Berg Balance Scale [23,32].
Table 1:Results of studies of training programs’ effects (n= 25) on the risk of falls in older adults.
Quality Assessment of Studies
The studies evaluated by the PEDro scale presented an average score of 8.6 points. One study scored 6 points [12], seven studies scored 7 points [4,11,16,27,28,31,32], eight studies scored 8 points [9,10,19,21,23,24,29,30], one study scored 9 points [25], and eight studies scored 10 points [7,15,17,18,20,22,26,33] (Table 2).
Table 2:Assessment Study Quality Using the PEDro Scale for Randomized Clinical Trials.
Y: Contemplated item.
*Item 1 does not contribute to the total score.
Discussion
This systematic review analyzed the effects of training
programs on the risk of falling in older adults. We mainly aimed
to elucidate whether the risk of falling is positively affected by
isolated or combined training programs, and thus contribute to the
prevention of falls and reduction in the risk of mortality. Regular
exercise influenced total daily physical activity and possibly induced
chronic physiological adaptations. We observed that all studies
that combined strength training programs with balance exercises
reduced the risk of falling [4,16-19,21,22,24,26,29]. The same was
seen in isolated strength training programs [15,20,24,25,27,30,33].
According to studies by Wolfson, et al. [34], Lord, et al. [35], and
Howe, et al. [36], the findings of this review can in part be attributed
to improvements in neuromuscular coordination by and “training
specificity” of the programs applied in the studies cited here.
However, positive effects on muscle mass, strength, composition,
power, and torque production, as well as changes in the mechanical
properties of the tendon, must be observed to explain the
significant reduction in the risk of falling [37,38]. Balance training,
as well as the evaluation of this variable, is considered an essential
component of fall prevention programs [39].
The loss of balance is directly related to decreases in muscle
mass, strength, and proprioception. According to Teixeira, et al.
[4], a strength training program for the quadriceps combined
with proprioception training can decrease the risk of falling in
postmenopausal women, in addition to increasing strength and
static and dynamic balance. Therefore, proprioception and strength
exercises are of great importance in reducing the risk of falling in
older adults. Sousa, et al. [7] found a decrease in the risk of falling
after the aerobic and balance training program. The risk of falling
also decreases when the strength protocol integrates aerobic
and balance training [28]. However, Cancela, et al. [9] observed
no decrease in the risk of falling after a strength, aerobic, and
balance training program. Ansai, et al. [10], who used an aerobic
and strength training program, likewise found no decrease. Both
studies used samples of older adults over 80 years old. This age
group has less organic adaptation, and the studies justified, in a
respective way, the differences attributable to the short period of
intention, application of light physical activity in a sitting position,
and failure to monitor falls daily.
No reduction in the risk of falling was also found in Varela, et
al. [12], who used isolated aerobic training in older adults with
mild cognitive impairment. According to Xu, et al. [40], aerobic
activities can improve balance and generates a positive effect on
the proprioception of older adults, given that aerobic exercises
decrease gait instability and can decrease degenerative processes
in the nervous and muscular systems. As such, aerobic exercises
can contribute to decreasing the risk of falls in older adults [41].
In studies that used isolated balance exercises, Jacobson, et al.[32],
Halvarsson, et al. [31], and Miko, et al. [23] reported a decrease
in the risk of falling. However, these results were not observed
in Hiyamizu, et al. [11]. A plausible explanation regarding the
divergent results is the lack of non-standardized protocols in the
experiments. According to Thomas, et al. [42], training programs
that offer an approach that includes resistance exercises, aerobic
components, and proprioception work can improve balance and
reduce the risk of falling in older adults. Falls are multifactorial
events that may be related to intrinsic and extrinsic factors. The
incidence of falls increases each year in the older population
worldwide, with a positive relation between age and the increase
in cases of falls.
Older adults can have several complications after a fall, such
as fractures and head injuries; indeed, falls account for 11% of the
mortality rate in this population [43-45]. Thus, increased mortality
in older adults is related to physical inactivity [46]. Moreover,
Thomas, et al. [42] reported that low-intensity exercises improve
the balance of older adults and contribute to decreasing the risk of
falling; adherence to moderate- to high-intensity training programs
is less attractive, leading to lower adherence, especially in older
adults. Based on the studies above, and in recognition of the
importance and relevance of reducing falling risk for maintaining
the quality of life and decreasing falls-related mortality in the older
population, we propose that strength and aerobic training programs
with proprioception exercises be recommended when and included
in designing interventions. The strengths of this systematic review
are that it was based on reliable results and full-text studies and
it included high-quality papers. Meanwhile, the main limitation of
this study is the lack of standardized assessment instruments for
the risk of falling. Nonetheless, the instruments were validated and
reliable, and thus, we chose to include all instruments.
Conclusion
This systematic review analyzed the effects of training programs on the risk of falls in older adults. Combined or multicomponent training programs, as well as isolated strength training, could decrease the risk of falling in older people. Further studies should standardize the protocols of training programs and assessment instruments, to enable further analysis of the aspects that brings better benefits: whether it is the training program, the modality to be worked on, or the modulation of the variables in the training.
Implications for Practice
The findings, based on the studies analyzed, demonstrated the importance and relevance of physical training programs for decreasing the risk of falling in people and older adults. Therefore, strength and aerobic training programs are recommended, along with balance exercises, for older adults.
Author Contributions
Silva A designed the research; Andrade G, Nascimento J, Ribeiro A and Barbosa C performed the research; Silva A, Silva J and Oliveira J analyzed the data; Silva A, Oliveira J wrote the paper; Silva A, Pertille A, Silva J and Oliveira J supervised the paper; all authors read and approved the final manuscript.
PRISMA 2009 Checklist
The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Acknowledgments
The authors would like to thank the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior-Brasil (CAPES) for the financial support through scholarships-Finance Code 001.
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