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- To inform health and fitness professionals about the prevalence of falls and fall related injuries in the geriatric population and how balance issues may affect their quality and quantity of life.
- To present peer-reviewed evidence to health and fitness professionals for the efficacy of resistance training (RT) on preventing falls and consequential injuries in the elderly population.
- To provide underlying mechanisms as to why resistance training (RT) may or may not be efficacious to fall prevention.
- To deliver a safe, practical and evidence-based resistance training program for health and fitness professionals to utilize in order to reduce or prevent falls in their elderly patients.
Key Words: Resistance Training, Geriatrics, Efficacy, Fall Prevention, Balance, Strength, Power
Age comes with many detrimental effects on the human body including sarcopenia and loss in muscle strength which are big risk factors associated with falling in the geriatric population. Fall prevention is becoming more of a subject of interest among healthcare professionals now that the baby boomer generation is coming to their golden years and fall rates have been increasing. 30% of people living at home in the United States over the age of 65 fall each year, with even higher rates when they live in nursing facilities (11). In addition, moderate to severe injuries occur in 20-30% of people who fall each year and can even lead to death (11). These statistics show the growing concern for having an effective training program that helps reduce falls in the elderly. There are several different interventions available for fall prevention in this population including different types of exercise programs, balance training, vitamin D supplementation, environmental and educational programs, etc., but we do not know how effective these treatments are (4). Since fall related injuries in the geriatric population are often associated with a decrease in muscle mass, strength and muscle function, resistance training is frequently used as a tool to restore muscle function and to prevent falls (17, 25, 35). Thus, this article is going to evaluate current research on the effects of resistance-training on preventing falls and restoring muscle function in elderly adults as well as the recommended resistance- training protocols for fall prevention in this population.
How Falling Effects the Quality of Life in the Geriatric Population
Falling can effect the elderly not only physically by way of bodily injury, but also psychologically. Falling could lead to a psychological trauma termed fear of falling. Fear of falling is common among elderly men and women in the community (2). Almost all of the elderly adults (85%) who are afraid of falling have had balance issues (2). Elderly adults who are fearful of falling are more likely to have a decreased quality of life than those who are not fearful of falling (2). Living in constant fear is not a favorable way to live and decreases the quality of life in the geriatric population. The fear of falling is the beginning of a detrimental cycle. When older people are fearful of falling it leads them to decrease their physical activity and consequently further contribute to sarcopenia and weakness which can lead to reduced walking speed and increased risk of disability and subsequently more falls in older people (11, 17, 28, 31). This loss of independence and inability to engage in ADL can contribute to depression in the geriatric population (38). These factors associated with falling negatively effect the quality of life in the older population.
Contributing Factors for Falls in the Elderly
Old age is inevitably associated with several risk factors for falls including loss in strength, muscle mass and power(3, 7, 10, 14, 21, 26, 30, 33, 52). Research shows that muscle weakness increases fall risk by 440% (44). Muscle weakness is common among the elderly population, especially weakness of the lower extremity muscles and it is a statistically important risk factor for falls (37). Decline in muscle mass with age increase is another critical element for this matter due to it’s contribution to frailty, decreased independence and decreased physical function such as effectively engaging in ADL (11, 16, 31). While muscle mass and strength are important for maintaining balance, power may be more influential to recover from a fall since a quick movement is necessary to correct any perturbation (18). One interesting find is that there is a larger magnitude of power loss in the elderly than strength (33). Also, elderly fallers have shown less power in the lower limbs compared to non fallers (51, 54). These findings in addition to the idea that movements associated with correcting and preventing a fall are more power oriented display the importance of power in the elderly for maintaining balance.
There are several different reasons why strength, muscle mass and power decline with increased age. Deficiencies in hormones such as testosterone and growth hormone (GH) in older adults could explain one reason why loss in muscle mass and strength is prevalent in this population (53). Muscle strength can also be affected by the reduction in EMG activity with age (34). Age related power decline could be consequences of diminished RFD activity and motor unit firing rate due to old age, as well as significant and preferential atrophy of type II muscle fibers as compared to type I muscle fibers (34). Figures A and B below shows the difference in type II muscle fibers between old age and young age (32). This preferential atrophy of fast-twitch muscle fibers is apparent in the elderly. Since these muscle fibers assist with short, quick movements they may be important in correcting balance issues when they occur.
Theory for RT Efficacy
There is overwhelming evidence that loss in muscle mass and strength in the elderly can be reduced by engaging in resistance training(8, 13, 15, 16, 20, 25, 50) (15). Strength is an important factor here as there is an association between a loss in strength in the lower limbs and ability to maintain balance after a gait perturbation is induced , similar to a real-life loss in balance (40). Furthermore, RT significantly increases RFD in older adults (1). Many practitioners would wonder if other types of exercise such as endurance training would be effective in increasing muscle mass, strength or power. Research has shown that muscle mass can’t usually be maintained into old age with regular endurance activities (42,43) and that RT is much more effective than aerobic exercise in increasing hypertrophy and strength in the geriatric population (27). In fact, elderly men who regularly engage in swimming or running endurance exercise had almost the same amount of muscle size and strength when compared to sedentary older adults (27). Therefore, while endurance exercise can be effective in the prevention of other conditions, it is not effective for the preservation of strength and muscle mass.
Is RT Effective for Preventing Falls?
There is a lack of evidence that proves that RT alone prevents falls directly (19, 41, 47). Although RT significantly increases strength and muscle mass, it is not proven to significantly reduce falls (23). RT was shown to have a large positive effect on strength, the closest measure of balance impairment and small to moderate effects on other aspects of impairment and functional limitation in older adults, but studies were unable to show that these effects of RT (increase in strength, decrease in impairment and functional limitation) translated into improvements in physical disability or reduction in falls (28). While some studies show that RT alone may significantly increase balance in the geriatric population (29), a meta-analysis (28) suggested that RT is not a significant component of balance. While the study (29) was well structured and it’s results seemed promising, it was just one single study that included 50 subjects, while the meta-analysis (28) included 62 different studies and 3,674 subjects. Thus, the weight of the argument leans toward the meta- analysis (28) and suggests that RT does not significantly improve balance alone. However, there is a good amount of evidence that RT in conjunction with balance training can improve balance in older people (18, 23, 47). Although poor muscle strength is a risk factor for falls, moderate to high intensity RT was not shown to have a greater effect on fall reduction than other types of exercise. This doesn’t mean that RT is not worth doing for the elderly population. It can be an effective part of a multicomponent training protocol that includes balance training as suggested earlier. For example, in one study they had subjects do 4 weeks of training including walking, cognitive exercises, and balance (9). Then, they implemented a 4-week resistance training program. The greatest strength gains and walking ability occurred after the resistance training part of the program was complete (9). Also, heavy resistance-training (HRT) results in significant increases in maximal strength and even greater improvements in maximal and explosive force production capacity, which is important for maintaining balance (20).
Power training (PT) may be an effective substitute for RT in a fall- prevention program. First off, PT and RT contribute to similar gains in muscular strength and hypertrophic gains (15, 22). While RT may increase power, PT is more specific to increasing power and therefore results in greater gains in power than RT (15, 22). Figure 1 shows comparisons of results from a RT program and a PT program (24). Second, while RT has shown no significant direct effect on increasing balance or decreasing falls in the geriatric population, there is evidence that PT results in a in significant increase in balance and reduction in falls in the elderly (5, 39, 40).
Also, muscle power might be more closely related to muscle function and performing activities of daily living than muscle strength (45, 46). More importantly, RT to PT both have similar increases in strength, but power trained elderly adults perform significantly better in functional tasks (36). These claims are further supported by similar findings in homogeneous studies (15, 48).
Specificity may also important in a fall prevention program. One study used weighted vests starting at 2% of the subject’s bodyweight and were adjusted depending on the subject’s performance to improve power and ADL (6). Their protocol called InVEST (Increased Velocity Exercise Specific to Task) included ADL specific exercises such as toe raises, sit to stands, step-ups, seated tricep dips and chest press. Results included significantly increased muscle power, balance and other improvements in functional performance.
Traditional RT has many benefits in the older population such as promoting hypertrophy and strength, but other training programs that focus on power and balance that are specific to the individual may be more beneficial for fall prevention.
Components of an Effective Fall Prevention Program
A high dose multicomponent exercise program that includes balance training, power training, is specific to the individual, and does not include only walking or aerobic exercise is the most effective to prevent falls in older adults (39, 49). As stated earlier, there are many health benefits associated with walking and RT but if the primary goal is to reduce fall rate in an individual, they would benefit more from a program that focuses more on balance and power training (49). Walking would not have a detrimental effect to a subject engaging in a fall prevention program, however if one wants to maximize the efficacy of the program on preventing falls then more time should be spent on balance and power rather than walking. Minimum criterion for an effective exercise dose for fall prevention is twice a week for at least 25 weeks (49).
There are several health benefits associated with resistance training in the older population such as reversing age-related sarcopenia and muscle weakness, improving bone strength, decreasing pain related to arthritis, etc. (8, 12, 13, 15, 20, 24, 50). However, resistance training alone is not an adequate tool to prevent falls in the geriatric population. One would benefit most from a high-dose, multicomponent training program that includes balance training, power training, and is highly specific to the person engaging in the program (39, 49).
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