1. Exercise and Falls Prevention Preliminary Results from a Community-Based Exercise Intervention April 3, 2009 Christian Thompson, Ph.D. Department of Exercise & Sport Science University of San Francisco

2. The Older Adult Continuum

3. This Can Happen to Both of Them!

4. Too Bad Its Not Funny… n Over 1/3 of people aged of 65+ fall each year n In 2004, over 1.8 million seniors were treated for fall-related injuries at emergency rooms n Approx. 400,000 fractures per year due to falls n Over 20% of hip fractures result in death in 1 yr n Problem will only continue to increase with changing demographics Sources: CDC, 2007; Kannus et al., 2005; Ngyuen et al., 2007

5. Relevant Health Data for California and San Francisco County n Over 25% of people living in San Francisco are over the age of 65 n Almost 12% of older Californians fell more than once in 2003 n Diagnosed diabetes increased from 15% in 2001 to 17.5% in 2005 n Diagnosed hypertension increased from 53% in 2001 to 60% in 2003 Source: UCLA Center for Health Policy Research, 2008

6. Factors Affecting Falls Extrinsic Factors External Issues –Weather or outdoor conditions – House clutter and obstacles –Poor lighting –Lack of adaptive devices in the home –Inappropriate footwear/clothing Intrinsic Factors Internal Issues –History of Falling –Chronic Diseases & Medical Conditions –Sensory/Vestibular Impairments –Medication Effects –Functional Level (Strength, Posture, Gait) Sources: (Rose, 2003; Tinetti et al., 1988; Carter, 2001; Lehtola et al., 2006) Risk with number of risk factors present

7. Regularly Implemented Intervention Strategies Multifactorial Address both I&E risks –Environmental hazards –Medication modification –Sensory deficits –Disease management –Exercise –Education Exercise-Only Address modifiable functional limitations –Lower body strength –Static/Dynamic balance –Flexibility –Gait modification –Cardiovascular Group vs. Individual Supervised vs. Unsupervised Sources: Lord et al., 1995; Province et al., 1995; Tinetti et al., 1994

8. Randomized Controlled Trials Multifactorial Interventions – 6 Studies Intervention Characteristics Exercise (6) Home Hazard Reduction (3) Day et al., 2002, Sjosten et al., 2007; Steinberg et al., 2000) Medical/Medication Intervention (5) Day et al., 2002; Steinberg et al., 2000; Shumway-Cook et al., 2007; Campbell et al., 1999; Sjosten et al., 2007 Vision (2) Day et al., 2002; Shumway-Cook et al., 2007 Education (2) Shumway-Cook et al., 2007; Sjosten et al., 2007 Nutrition (1) Swanenburg et al., 2007

9. Randomized Controlled Trials Multifactorial Interventions Relevant Findings Falls Reduction n Significant reduction in falls in 3 of 6 studies –Day et al., 2002; Steinberg et al., 2000; Swanenburg et al., 2007 Fall Risk Reduction n Improvement in some/all fall risk factors in 5 of 6 studies –Measured by Balance assessment inventories, Strength, Gait Analysis, Agility/Dynamic Balance Assessments, Balance Confidence/Fear of Falling scales –Only Sjosten, et al., 2007 did not report improvement Limitations n Variability in participant selection, exercise dose, exercise program content, program duration n Questionable statistical analyses

10. Randomized Controlled Trials Exercise-Only Interventions – 9 Studies Included Exercise Program Characteristics Resistance Training (7) – Barnett et al., 2003; Freiberger et al., 2007; Woo et al., 2007; Suzuki et al., 2004; Luukinen et al., 2007; Rubenstein et al., 2000; Lin et al., 2006 Static Balance Training (5) – Barnett et al., 2003; Freiberger et al., 2007; Madureira et al., 2007; Suzuki et al., 2004; Rubenstein et al., 2000 Agility/Dynamic Balance Training (8) Gait Enhancement Training (4) – Barnett et al., 2003; Madureira et al., 2007; Suzuki et al., 2004; Rubenstein et al., 2000 Aerobic/Cardiovascular Training (4) – Barnett et al., 2003; Freiberger et al., 2007; Luukinen et al., 2007; Rubenstein et al., 2000 Flexibility Training (6) – All except Madureira 2007 & Suzuki 2004 Tai Chi (4) – Barnett et al., 2003; Woo et al., 2007; Li et al., 2005, Lin et al., 2006 Supervised Group Exercise (4), Home-based Exercise (1), Combination (4)

11. Randomized Controlled Trials Exercise-Only Interventions Relevant Findings Falls Reduction n Significant reduction in falls in 6 of 9 studies –Barnett et al., 2003; Freiberger et al., 2007; Li et al., 2005; Madureira et al., 2007; Suzuki et al., 2004; Rubenstein et al., 2000 Fall Risk Reduction n Improvement in some/all fall risk factors in 5 of 6 studies –Measured by Balance assessment inventories, Strength, Gait Analysis, Agility/Dynamic Balance Assessments, Balance Confidence/Fear of Falling scales –Only Woo, et al., 2007 did not report improvement Limitations n Variability in participant selection, exercise dose, exercise program content, program duration n Questionable statistical analyses

12. Conclusions Concerning Exercise for Falls Prevention n Exercise has been shown to exert a strong effect on functional level and modifiable intrinsic falls risk factors n Exercise has been shown in several studies to reduce future falls n Dose-response studies are needed to determine optimal training recommendations

13. Purpose & Hypotheses Determine the effect of a 12-week progressive functional training program on falls risk, balance confidence, perceptions of health and falls occurrence in community-dwelling older adults who have sustained at least one accidental fall in the past 6 months

14. Intervention Description 12-week Progressive Program Three 4-week phases n Dynamic warm-up n Sensory integration exercises n Strength training n Balance training n Gait enhancement training n Dynamic cool-down 60 Minutes, 2 days per week Led by certified fitness professionals

15. ExerciseWeek 4Week 8Week 12 Hip Rotations Seated 30 sec each Seated 30 sec each Standing 30 sec each Stand w/ Rotating Head (eyes fixed) – 30 sec No MarchMarch 15 secMarch 30 sec Chair Squats w/ Forward Reach 2x153x153x25 Dumbbell Underhand Front Raise (Chest) Seated 2x15 Standing 3x15 Standing 1 Arm 3x15 each Dumbbell Cobra (Back) Seated 2x15 Standing 3x15 Standing 1 Arm 3x15 each Side Steps (Wide Steps to Feet Together) 2 steps Forward Reach 60 sec 3 steps Same Reach 90 sec 4 steps Opposite Reach 120 sec Mobility Ladder Pattern Forward Stepping 2x through Alt. Wide & Narrow Steps 2x through Diagonal Steps to 1 Leg Balance 2x through Partner Squat & Ball Pass Face-to-Face 1x20 each Side-by-Side 2x20 each Side-by-Side Low to High 2x20 each Exercise Progression Examples

16. Outcome Measures n Physiological Assessments –Functional Reach Test (Limits of Stability) –30 sec Chair Stand (Lower Body Strength) –Timed Up-And-Go (Agility & Dyn. Balance) n Questionnaires –Activity Specific Balance Confidence Scale –SF-12 Quality of Life Questionnaire n Falls Occurrence –Monthly Phone Interviews for 1 year

17. Study Sample n Community-dwelling older adults 65 yrs n Sustained accidental fall in last 6 mos –FICSIT falls definition n Must be able to ambulate 30 feet w/o AD n Free of significant sensory/vestibular dysfunction, PD, uncontrolled metabolic disease, uncontrolled cardiovascular disease n Available for study duration

18. Total Phone Contacts 82 Attended Screening 61 Did Not Qualify 10 Qualified and Did Not Enroll 6 Qualified and Enrolled 45 Did Not Qualify/Not Interested 21 Completed < 20 Visits 7 Dropped Out 3 Recruitment & Intervention Completed 20+ Visits 35 Controls 40

19. Physiological Measures ANCOVA – Baseline as Covariate % Change p =.0001 p =.008 p =.04

20. Acknowledgements Funding: San Francisco Dept. Aging & Adult Services California Wellness Foundation University of San Francisco Faculty Development Fund Community Partners: 30 th Street Senior Center, San Francisco Senior Centers, Inc., Kaiser San Francisco, San Francisco Examiner, Fromm Institute for Lifelong Learning at USF Research Associates/Assistants: Dr. Diana Lattimore, Irina Fedulow, Brigitte Dubon, Sarah Simunovich, Jermelle Newman, Taylor Harrington, Sarah Wallenrod, Patricia Bufalini, Matt Lieb, Ben Dessard

21. Dr. Christian Thompson Department of Exercise & Sport Science University of San Francisco 2130 Fulton Street San Francisco, CA 94117 cjthompson@usfca.edu (415) 422-5270