Exercise Interventions to Reduce Falls in Elderly Care Residents

Introduction and Research Question

This paper addresses the following research question: What is the effectiveness of exercise-based interventions in reducing falls in older adults living in residential care facilities? Four peer-reviewed studies are summarized and then compared in the discussion section below.

Study Summaries

Paper 1: Virtual Reality Complex vs. Balance Exercise Training (Lim et al., 2017)

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 delivered through virtual reality. The researchers conducted a randomized trial over the course of five weeks with 20 elderly participants over the age of 65.

The 20 participants were placed into 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 practiced balance techniques only. The researchers measured knee extension torque and dynamic balance.

The study showed that elderly patients who received virtual reality training using the complex exercise protocol displayed improvements in both balance and muscle strength. The complex exercise regimen was found to be more beneficial than basic balance training. The researchers concluded that, in order to effectively reduce the risk of falls in the elderly population, care providers should focus on using the complex exercise regimen — incorporating strengthening, flexibility, endurance, and balance exercises. The study demonstrates that virtual reality tools can help elderly patients achieve not only better balance but also better mobility, agility, and overall strength. While the study makes some connection to residential care facilities, it primarily shows that muscle-strengthening exercises are most effective for fall prevention.

Paper 2: Group Exercise Programs in Long-Term Care Facilities (Faber et al., 2006)

Faber, Bosscher, Paw, and van Wieringen (2006) find that group exercise programs are effective in preventing falls among elderly individuals who are not frail. If an elderly person is frail, however, the study shows that exercise is unlikely to make a meaningful difference. Frailty is thus the determining factor with regard to whether an elderly person is at greater risk of falling. Conversely, if a person is elderly but pre-frail and engaged in an exercise program, that person's risk of falling is further reduced.

The researchers indicate that the degree of frailty is important to consider, noting that "exercise interventions may be effective in preventing, delaying, or reversing the frailty process" (p. 886). However, the condition of the elderly participants played a major role in determining individual risk levels with respect to falls. To gather evidence, Faber et al. (2006) drew from 15 long-term care facilities in Amsterdam, randomly selecting 278 participants. Two exercise programs were used for the intervention: one focused on functional walking and the other on balance.

The study explicitly describes its statistical analysis methods and provides numerous charts demonstrating how the data were assessed. In the methodology section, the researchers explain how they measured physical performance scores to determine whether the training was effective. In the discussion section, they examine the results and address the implications of the evidence. The researchers conclude that falls prevention programs can benefit from challenging but safe exercise training, though this benefit applies only to pre-frail participants.

Paper 3: Conventional vs. Virtual Reality Balance Training in Turkish Nursing Homes (Yesilyaprak et al., 2016)

Yesilyaprak, Yildirim, Tomruk, Ertekin, and Algun (2016) conducted a study to compare conventional exercise training on balance with virtual reality-based balance training for elderly patients in nursing homes. The study took place across several nursing homes in Turkey. Eighteen participants between the ages of 65 and 82 were selected. The researchers found that it made no significant difference whether balance training was conducted using conventional methods or virtual reality-based methods. In both cases, the Berg Balance Score improved, as did left leg stance and tandem stance duration. The researchers concluded that balance training can benefit elderly patients, but those with a history of falls or who have entered a frail stage are less likely to benefit.

It is therefore important to consider the sample used in this study. While the researchers noted that "balance and gait impairments" are important factors when attempting to understand what leads to falls in elderly patients (Yesilyaprak et al., 2016, p. 191), they wanted to determine whether one method of balance training was preferable to another. The study's approach relied on a relatively small sample: 7 participants in the virtual reality-based balance training program and 11 in the conventional training program. Drawing conclusive remarks from a sample of only 7 or 11 participants risks premature conclusiveness. The sample size should be enlarged in future research to enhance external validity.

Paper 4: Exergaming with the Nintendo Wii Fit for Frail Elderly Patients (Fu et al., 2015)

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 play in which the participant physically exercises alongside the game. The Nintendo Wii Fit was used as a training tool to help elderly patients with a history of falls develop better balance. The Wii Fit requires users to be actively engaged — standing, moving, balancing, reaching, and swinging as demanded by the game. The researchers conducted a randomized controlled clinical trial in a nursing home for the elderly, with 60 participants characterized as frail based on their falls history. The intervention consisted of a six-week course of balance training with two groups: one receiving conventional exercise training and the other receiving balance training via the Nintendo Wii Fit.

The researchers used the physiological profile assessment score in conjunction with falls incidence rates and intention-to-treat statistical analysis. Both forms of training improved participants' physiological profile assessment scores and decreased falls incidence. However, the group that trained with the Nintendo Wii Fit showed significantly greater improvement in both their physiological profile assessment and their rate of falls. The researchers concluded that exercising with the Wii Fit can meaningfully decrease fall risk even among frail elderly patients. They recommend using the Nintendo Wii Fit as an exercise training tool in nursing homes to develop better balance and coordination and thereby reduce the risk of falling.

Discussion

Lim et al. (2017) show that when exercise training is focused on strength conditioning, the elderly population benefits more than from training that focuses solely on balance. However, Faber et al. (2006) demonstrate that frailty is the most important factor, as it determines whether an elderly person is even capable of benefiting from fall prevention training. In other words, exercise training shows value primarily when the elderly person is in a pre-frail stage. Once a patient has entered a frail stage, exercise training may be too late to produce meaningful benefit.

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 Fit. Their findings directly challenge those of Faber et al. (2006). It is worth noting that the Faber et al. (2006) study included more than four times as many participants as the Fu et al. (2015) study and was conducted across multiple nursing homes, whereas Fu et al.'s study was limited to a single nursing home. The study by Yesilyaprak et al. (2016) also examined multiple nursing homes — and although they were located in Turkey, the evidence may still carry some external validity relevant to the research question concerning the effectiveness of exercise-based interventions in residential care facilities.

Fu et al.'s (2015) study also resembles that of Lim et al. (2017) in that it incorporated more overall conditioning, given that participants had to be physically active throughout the video game. This active engagement may have influenced the conditioning and endurance of participants, making them more physically robust over the six-week period. Taken together, the studies by Lim et al. (2017) and Fu et al. (2015) suggest that the more impactful and conditioning-focused the training is — provided it remains safe and not overly strenuous — the more likely it is to produce a positive effect on the elderly person's health and fall prevention outcomes.

Conclusion

The major finding across all four studies is 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 notable difference is that Faber et al. identified frailty as a mitigating factor: elderly persons who were frail did not benefit significantly from functional walking exercises or balance training alone. This finding is not entirely surprising, given that neither of those interventions places substantial emphasis on conditioning. The studies by Lim et al. and Fu et al. specifically demonstrated that reducing fall risk requires a greater focus on conditioning exercises, which strengthen the body and improve the elderly person's capacity to move and avoid falling.

Future research on this topic should pursue longitudinal designs to assess whether more extensive use of tools such as the Nintendo Wii Fit produces lasting benefits among elderly residents in nursing homes. Even without such longitudinal data, the four studies reviewed here collectively answer the research question: exercise-based interventions are effective in reducing the risk of falls in older adults living in residential care facilities.

References

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), 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), 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, 64–67.

Yesilyaprak, S. S., Yildirim, M. S., 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), 191–201.