Effectiveness of muscle strengthening and description of protocols for preventing falls in the elderly: a systematic review

Ishigaki, Erika Y.; Ramos, Lidiane G.; Carvalho, Elisa S.; Lunardi, Adriana C.

doi:10.1590/S1413-35552012005000148

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Brazilian Journal of Physical Therapy

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Systematic Review • Braz. J. Phys. Ther. 18 (02) • Mar-Apr 2014 • https://doi.org/10.1590/S1413-35552012005000148 copy

Effectiveness of muscle strengthening and description of protocols for preventing falls in the elderly: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Background:

Falls are a geriatric syndrome that is considered a significant public health problem in terms of morbidity and mortality because they lead to a decline in functional capacity and an impaired quality of life in the elderly. Lower limb muscle strengthening seems to be an effective intervention for preventing falls; however, there is no consensus regarding the best method for increasing lower limb muscle strength.

Objectives:

To analyze the effectiveness of lower limb muscle strengthening and to investigate and describe the protocols used for preventing falls in elderly subjects.

Method:

We performed a systematic review of randomized and controlled clinical trials published between 2002 and 2012 in the databases PubMed, EMBASE, Scopus, Web of Science, and PEDro that cited some type of lower limb muscle strengthening protocol and that evaluated the incidence of falls as the primary outcome exclusively in elderly subjects. Twelve studies met the inclusion criteria. Qualitative analysis was performed by independent reviewers applying the PEDro scale.

Results:

The data obtained from the selected studies showed lower fall rates in the intervention groups compared to controls. Six studies described the lower limb muscle strengthening protocol in detail. High methodological quality was found in 6 studies (PEDro score â‰¥7/10 points).

Conclusions:

The methodological quality of the studies in this area appears to leave little doubt regarding the effectiveness of lower limb strengthening exercises for preventing falls in elderly subjects, however the interventions in these studies were poorly reported.

physical therapy; elderly; falls; strength training; rehabilitation; review

Author (year)	Design	Aim	Outcome	PEDro
Clemson et al. ¹⁴ (2010)	RCT	Investigate the feasibility and effectiveness of a fall prevention program	Falls, Balance, Strength, Quality of life	8/10
Smulders et al. ¹⁵ (2010)	RCT	Evaluate the effectiveness of the Nijmegen Falls Prevention Program in reducing falls in the elderly with osteoporosis	Falls, Balance	8/10
Spink et al. ¹³ (2011)	RCT	Determine the efficacy of an intervention in podiatry in prevention falls in elderly	Falls, Strength, ROM, Balance	8/10
Shumway-Cook et al. ¹⁷ (2007)	RCT	Evaluate the effectiveness of an intervention on falls and risk factors in the elderly	Falls, Balance	8/10
Clemson et al. ¹⁹ (2004)	RCT	Verify the effectiveness of a multi-faceted program for reducing falls	Falls, Strength	7/10
Clemson et al. ¹² (2012)	RCT	Determine the effectiveness of strength training and muscle balance in % of falls in elderly	Falls, Strength, Balance, ADL	7/10
Iwamoto et al. ¹⁶ (2009)	RCT	Investigate the effect of a training program for preventing falls	Falls, Flexibility, Balance, Strength, Gait	6/10
Becker et al. ²⁰ (2003)	CRT	Evaluate the effectiveness of a multifaceted, nonpharmaceutical intervention on incidence of falls and fallers	Falls, Balance	6/10
Lord et al. ¹⁸ (2005)	RCT	Determine if a program of individualized fall prevention can reduce the risk of falls in the elderly	Falls, Strength, Balance	6/10
Beling and Roller ²³ (2009)	RCT	Measure the effectiveness of a balance program on muscle strength, balance, and gait in fall-prone older adults over the 3-month study	Falls, Balance	4/10
Lord et al. ²¹ (2003)	RCT	Determine if a group exercise program can improve physical functioning and reduce the % of falls in the elderly	Falls, Balance	3/10
Jensen et al. ²² (2002)	CRT	Investigate if a multifactorial intervention program can reduce falls and injuries related to falls.	Falls	3/10

Author (year)	Subjects	N	Outcomes	Assessment of endpoint
Clemson et al. ¹⁴ (2010)	Community	34	IG had the lowest % of falls, better dynamic balance, better MS knee, better self-efficacy balance and fewer falls than CG.	monthly calendar of falls
Smulders et al. ¹⁵ (2010)	Hospital	96	IG% showed fewer falls and improved balance confidence more than CG.	monthly calendar of falls
Spink et al. ¹³ (2011)	Community	305	IG showed fewer falls, better MS, better ROM, and better balance than CG.	monthly calendar of falls
Shumway-Cook et al. ¹⁷ (2007)	Community	53	IG showed the lowest% of falls, better balance, better MS for the lower limbs and better mobility than CG.	monthly calendar of falls
Clemson et al. ¹⁹ (2004)	Community	317	LIFE showed better balance and fewer falls than SEG or CG; SEG and LIFE showed better dynamic balance and balance confidence than CG; LIFE showed more improvement for MS ankle gain, ADL and on the Physical Activity Scale for the Elderly than CG.	monthly calendar of falls
Clemson et al. ¹² (2012)	Community	310	IG showed fewer falls, better confidence maintenance and a greater ability to prevent falls during ADL than CG.	monthly calendar of falls
Iwamoto et al. ¹⁶ (2009)	Community	66	IG showed the lowest% of falls, better flexibility, better body balance, better MS and better walking ability than CG.	weekly self-report
Becker et al. ²⁰ (2003)	Community	981	IG% showed lower falls in the first and last quarter of the study than CG.	monthly calendar of falls
Lord et al. ¹⁸ (2005)	Community	620	% of falls was equal in EIG, MIG, and CG. EIG and MIG had better sitting and standing than CG; EIG had fewer risk factors for hamstring injury and higher MS than CG	monthly calendar of falls
Beling and Roller ²³ (2009)	Community	23	IG had fewer falls during the intervention and required more ankle and knee MRIs than CG.	Self-report
Lord et al. ²¹ (2003)	Community	551	IG showed fewer falls and better reaction time for "step, step away from" than CG.	monthly calendar and recording by a nurse
Jensen et al. ²² (2002)	Aged-care facility	439	IG showed lower % of falls and lower % of femur fractures than CG; IG was greater for the first fall than CG.	self-reporting and recording by a nurse

Author (year)	CONTROL	PROTOCOL	INTERVENTION	EXERCISES + CO-INTERVETION	IMPACT OF FALLS
Clemson et al. ¹⁴ (2010)	CG=no intervention	Unquantified exercises incorporated in ADL	IG=bend knees, climbing stairs, sitting and standing, walking sideways and pick up objects on the floor	Balance exercises (reduce support base, one foot ahead of the other during ADL)	Falls LIFE=12, CG=35. LIFE=Self improves efficiency falls during 6 months
Smulders et al. ¹⁵ (2010)	CG=usual care	11 sessions for 5 ½ weeks	IG=climbing stairs, spine extension, sitting and standing, brisk walking	Correction of gait + obstacle course + walking exercises at different speeds and directions + training in fall techniques	non-significant
Spink et al. ¹³ (2011)	CG=routine podiatry care	30 min, 3x/week for 6 months	IG=home exercises to strengthen the feet and ankles with increased load	Orthoses + guidance on shoes + guidance on home exercises for ankles and feet + education + foot care	IG fall 36% less than in CG
Shumway-Cook et al. ¹⁷ (2007)	CG=orientation	1 h, 3x/week for 12 months	IG=LL strengthening with incremental load from 1 to 10kg	UL strengthening exercises with incremental load + static and dynamic balance + education	Falls IG <25% than CG
Clemson et al. ¹⁹ (2004)	CG=social visits	2 h, 1x/week for 7 weeks	IG=exercises performed within ADL, mobility skills without load	Education + adaptation of environment + medication adjustments + vision correction	Falls IG<31% than CG
Clemson et al. ¹² (2012)	CG=stretching	Unquantified exercises incorporated into ADL	LIFE=bend knees, climbing stairs, sitting and standing, walking sideways and picking up objects on the floor	SEG=balance exercises (reduce support base, one foot in front of the other during ADL)	LIFE=172, SEG=193, and CG=224.
Iwamoto et al. ¹⁶ (2009)	CG=no intervention	30 min, 3x/week for 5 months	IG=sitting and standing	Calisthenics + balance training (static tandem + tandem gait + one-leg support) + gait training	Falls IG=0 and CG=12%
Becker et al. ²⁰ (2003)	CG=no intervention	75 min, 2x/week for 12 months. 2 sets of 10 repetitions with a load of 75% of 1 maximal resistance	IG=ankle movements with load increase	Balance exercises + education + environmental adaptation + hip protectors	Falls IG decreased from 1406 to 1022. Time for 1st decrease was similar in IG and CG until the 6th month follow-up
Lord et al. ¹⁸ (2005)	CG=no intervention	2x/week for 12 months	IG=individualized intervention to improve strength, coordination, balance, vision, and peripheral sensitivity	Home exercises + written guidelines on how to maximize the vision	No difference between groups
Beling and Roller ²³ (2009)	CG=no intervention	3x/week for 12 weeks	IG=sit-up while holding a ball, increasing weight and repetitions + incremental plantar flexion repetitions	Balance strategies (hip, ankle, and step strategies) + sensory training exercises to increase ROM	Falls IG=11, CG=20 in the last year; Fall IG=1, CG=4 during the study
Lord et al. ²¹ (2003)	CG=stretching and relaxation	1 h, 2x/week for 12 months	IG=muscle group strengthening exercises for ankle dorsiflexors + knee extensors + hip abductors + hip side-flexors	Balance exercises (tandem foot standing, walking, standing on one leg, altering base of support, weight transfers, lateral movement challenges, shifts away from center of gravity) + relaxation + stretching	Falls IG<22% than CG
Jensen et al. ²² (2002)	CG=no intervention	2-3x/week for 11weeks	IG=self-regulated moderate intensity strengthening exercises and balance training	Balance exercises + walking + safe transfer	Falls IG=0-16, CG=0-26; IG=26% after a fall and CG=33%; IG time to first fall larger than CG

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[1] Correspondence Adriana C. Lunardi Universidade de São Paulo Faculdade de Medicina Departamento de Fisioterapia Rua Cipotânea, 53 CEP 05360-000, São Paulo, SP, Brazil e-mail: adrianalunardi@usp.br