Exercise Training with Elderly to Reduce the Risk of Falls

Scenario 3: Falls Prevention
Research Question: What is the effectiveness of exercise-based interventions in reducing falls in older adults living in residential care facilities?
Paper 1 (300 words):
The study by Lim, Cho, Kim, Kim and Yoon (2017) focuses on the role that virtual reality exercise training can play in the lives of elderly patients to help reduce falls. The researchers sought to compare the effectiveness of balance training to the effectiveness of complex exercise training, both using the medium of virtual reality in order to receive the training. The researchers conducted a randomized trial that took place over the course of 5 weeks with 20 elderly participants over the age of 65.
The 20 participants were placed in two groups—one receiving virtual reality complex exercise training and the other receiving virtual reality basic balance exercise training. There were ten sessions of one hour each. The complex exercise group practiced exercises including “strengthening, flexibility, endurance, and balance exercises” (p. 64). The basic balance exercise group simply practiced balance techniques. The researchers measured knee extension torque and dynamic balance.
The study showed that when elderly patients received virtual reality training using the complex exercises protocol, they displayed improvements in their balance as well as in their muscle strength. The complex exercise regimen was found to be more beneficial than the basic balance training. The researchers thus concluded that in order to effectively reduce the risk of falls in the elderly population, care providers should focus more on using the complex exercise regimen with strengthening exercises, flexibility exercises, endurance exercises and balance exercises. The researchers show that virtual reality tools can help elderly patients obtain not only better balance but also better mobility, agility, and all strength. The study makes some connection to residential care facilities, but it mainly shows that when it comes to exercise training, muscle strengthening exercises are best for preventing falls.
Paper 2 (300 words):
Faber, Bosscher, Paw and van Wieringen (2006) find that group exercise programs are effective in preventing falls among elderly population who are not frail. If the elderly are frail, the study shows that no amount of exercise is going to make a difference. Frailty is thus the determining factor with regard to whether an elderly person is at greater risk of falling. However, if the person is elderly but pre-frail and engaged in an exercise program, that person’s risk of falling becomes even less.
The researchers indicate that the degree of frailty is important to consider and they show that “exercise interventions may be effective in preventing, delaying, or reversing the frailty process” (p. 886), but the problem that they encountered in their research was that the condition of the elderly persons played a major role in determining the risk level for that individual with respect to falls. To gather evidence for their research, Faber et al. (2006) turned to 15 long term care facilities in Amsterdam. 278 participants were randomly selected. Two exercise programs were selected for the intervention. The first focused on functional walking and the second on balance.
The study explicitly explains its statistical analysis methods and provides numerous charts to show how all the information was assessed. In the methodology section, the researchers explain how they measured for the physical performance score of the patients to determine whether the training they received was effective. In the discussion section of the study, the researchers focus on examining the results of the study, and discussing the meaning and implications of the evidence. The researchers conclude that falls prevention programs can benefit from challenging but safe exercise training programs, though only for pre-frail participants.
Paper 3 (300 words):
Ye?ilyaprak, Y?ld?r?m, Tomruk, Ertekin and Algun (2016) conducted a study to compare conventional exercise training on balance for elderly patients in a nursing home to virtual reality-based training on balance. The study took place across several nursing homes in the nation of Turkey. 18 participants in total between the ages of 65 and 82 were selected for the study. The researchers found that it made no difference whether the training in balance was conducted using conventional training methods or virtual reality-based methods. In both instances, the Berg balance score improved, as did left leg stance and tandem stance duration. The researchers concluded that balance training can help elderly patients—but patients with a history of falls or who have entered into a frail stage are less likely to benefit from balance training.
That is why it is important to consider the sample used for this study. While the researchers noted that “balance and gait impairments” are important factors to consider when attempting to understand what leads to falls for elderly patients (Ye?ilyaprak et al., 2016, p. 191), they wanted to see if one method of balance training was preferable to another. The study’s approach to the problem was to use a relatively small sample size, however. The sample consisted of 7 participants in the virtual reality-based training in balance program and 11 participants in the conventional training in balance program. To make any conclusive remarks on the subject of balance training after only testing the program on 7 or on 11 participants would be to make the mistake of premature conclusiveness. The sample size should be enlarged to enhance the study’s external validity.
Paper 4 (300 words): 
Fu, Gao, Tung, Tsang and Kwan (2015) examine the role that exergaming can play in training elderly patients to avoid falls. Exergaming is a type of video game playing in which the participant physically exercises along with the game. The Nintendo Wii Fit was used by the researchers as a training tool to help elderly patients with a history of falls to learn better balance technique. The Wii Fit is a game that allows the user to be actively engaged—i.e., standing, moving, balancing, reaching, swinging as is required for the game. For their study, they conducted a randomized controlled clinical trial in a nursing home for the elderly. The participants numbered 60 elderly patients. The patients were described or characterized as frail based on their falls history. The intervention used by the researchers consisted of a six week course of balance training. There were two groups used for the study. One group received conventional training exercise training. The other group received balance training via the Nintendo Wii Fit equipment.
The researchers used the physiological profile assessment score and coupled it with the incidence of falls along with intention to treat statistical analysis. The outcome of the study was that both forms of training improved the physiological profile assessment score of the participants and decreased the falls incidence rate. The group that trained in balance with the Nintendo Wii Fit, however, showed significantly better improvement in both their physiological profile assessment and in their rate of falls. The researchers thus concluded that by exercising with the Wii Fit, frail elderly could decrease their risk of falls significantly. They recommend using the Nintendo Wii Fit as a training exercise tool for frail elderly in nursing homes to teach them better balance and coordination and thus reduce the risk of falling.
Discussion (600 words) 
Lim et al. show that when exercise training is focused on strength conditioning, the elderly population benefits more from the training program than from training that only focuses on balance. However, the study by Faber et al. (2006) shows that frailty is the most important factor, as frailty is what determines whether the elderly person is even capable of avoiding falls in the first place. Exercise training in other words is only shown to have value if the elderly person is in a pre-frail stage. When a patient is in a frail stage, exercise training is too late to do any real good.
On the other hand, Fu et al. (2015) showed that even frail elderly patients can decrease their risk of falling when receiving balance training using the Nintendo Wii. Their study challenges that study by Faber et al. (2006). The study by Faber et al. (2006) had more than 4x as many participants as the study by Fu et al. (2015) and was conducted across a variety of nursing homes, whereas Fu et al.’s study was conducted at a single nursing home. The study by Ye?ilyaprak et al. (2016) also looked at numerous nursing homes, and though they were in Turkey, the evidence may still have some external validity that could be useful in answering the researcher question of what is the effectiveness of exercise-based interventions in reducing falls in older adults living in residential care facilities.
Still, Fu et al.’s (2015) study was similar to that of Lim et al. (2017) in that it included more conditioning because it was conducted via a video game in which the participants have to be active. The activity of playing the game could have had an impact on the conditioning and endurance of the elderly participants, thus making them more robust in terms of constitution after a six week period. Thus, the study by Lim et al. (2017) and the study by Fu et al. (2015) indicates that the more impactful and focused on conditioning the training is—all while be safe and none too strenuous—the more likely it is to have a positive effect on the elderly person’s health.
A longitudinal study should be conducted to address some of the gaps in these studies. For instance, none of the studies took place over a substantial length of time—i.e., a 1-2 year period or even a 5 to y 10-year period. The older the elderly patient gets, the greater the risk of suffering from falls. For that reason, it would be helpful to see if the virtual reality game training or the Wii Fit training has a long term beneficial impact over a substantial period of time. That is why a longitudinal study would be helpful: it would show the effect of this type of exercise training over a 1 or 2 or 10 year period. Exercise training should be viewed with this long term outlook in mind, especially with elderly people. They may be engaged for a period of six weeks but what would be very good to know is if they can maintain that level of engagement for six months or for a whole year—or what happens if the interest in the Wii Fit game drops?
Overall, the findings of the four studies show that exercise-based interventions are helpful in reducing falls in older patients living in residential care facilities. The more that the exercise-based interventions focused on complex exercises along with balance, conditioning, and other beneficial techniques for elderly persons, the more effective the intervention was.
Conclusion
The major points of the four studies are that exercise-based interventions do help in reducing the risk of falls for elderly patients (Faber et al., 2006; Fu et al., 2015; Lim et al., 2017; Yesilyaprak et al., 2016). The only difference is that Faber et al. showed that frailty is a mitigating factor. In the study by Faber et al., it was shown that elderly persons who were frail did not benefit much from functional walking exercises or from balance training. This, however, is not surprising because there is not much conditioning in either intervention. The studies by Lim et al. and Fu et al. specifically showed that in order to reduce the risk of falls, more focus should be placed on conditioning exercises, because these actually help to strengthen the body and improve the elderly person’s ability to move about and avoid falling.
The future of research on this topic should look at longitudinal studies to see whether there are long term benefits of more extensive use of tools like the Nintendo Wii Fit among elderly residents in a nursing home. Even without this type of study provided, the researchers answered the research question, showing that exercise-based interventions do help to reduce the risk of falls in older adults in residential care facilities.
Reference List 
Faber, M.J., Bosscher, R.J., Paw, M.J.C.A. and van Wieringen, P.C., 2006. Effects of
exercise programs on falls and mobility in frail and pre-frail older adults: a multicenter randomized controlled trial. Archives of physical medicine and rehabilitation, 87(7), pp.885-896.
Fu, A.S., Gao, K.L., Tung, A.K., Tsang, W.W. and Kwan, M.M., 2015. Effectiveness of
exergaming training in reducing risk and incidence of falls in frail older adults with a history of falls. Archives of physical medicine and rehabilitation, 96(12), pp.2096-2102.
Lim, J., Cho, J.J., Kim, J., Kim, Y. and Yoon, B., 2017. Design of virtual reality training
program for prevention of falling in the elderly: A pilot study on complex versus balance exercises. European Journal of Integrative Medicine, 15, pp.64-67.
Ye?ilyaprak, S.S., Y?ld?r?m, M.?., Tomruk, M., Ertekin, Ö. and Algun, Z.C., 2016.
Comparison of the effects of virtual reality-based balance exercises and conventional exercises on balance and fall risk in older adults living in nursing homes in Turkey. Physiotherapy theory and practice, 32(3), pp.191-201.