Personal Choice Report - Stay On Your Feet®

Personal Choice Report Benefits of recreation activities for falls

prevention

Prepared by: Injury Control Council of Western Australia

Date: September 2015

Personal Choice Report

September 2015

Page 1

Suggested citation: Injury Control Council of Western Australia (2015). Stay On Your Feet® Personal Choice Report - Benefits of recreation activities for falls prevention. West Perth: Injury Control Council of Western Australia.

Important disclaimer: All information and content in this Material is provided in good faith of the Injury Control Council of

Western Australia (ICCWA), and is based on sources believed to be reliable and accurate at the

time of development. The Injury Control of Western Australia and their respective officers,

employees and agents, do not accept legal liability or responsibility for the Material, or any

consequences arising from its use.

When considering participating in a recreational activity it is important to factor in any potential

risks of participating in the activity. This document outlines potential risks of each recreational

activity on balance, however it does not consider other risks that may exist beyond balance. If you

have any queries or concerns about your potential risks of participating in a recreational activity it

is recommended that you speak to your doctor prior to participating.

Contact information: For further information contact Stay On Your Feet® on 1300 30 35 40 or

[email protected]

mailto:[email protected]


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Table of Contents

Acknowledgements ...................................................................................................................... 4

Foreword ....................................................................................................................................... 5

Executive Summary ...................................................................................................................... 6

Introduction ................................................................................................................................... 7

Epidemiology of falls .................................................................................................................. 7

Consequences of falls ............................................................................................................... 7

The future impacts of falls.......................................................................................................... 7

Causes of falls ........................................................................................................................... 8

Balance ..................................................................................................................................... 8

Injury Control Council of Western Australia ............................................................................... 8

Stay On Your Feet® ................................................................................................................... 8

Falls Prevention Programs ........................................................................................................... 9

Current falls prevention programs .............................................................................................. 9

Ideal Characteristics of a falls prevention exercise program ...................................................... 9

Recreational Activities ................................................................................................................ 11

Benefits of recreational activities ............................................................................................. 11

Older adults’ participation in recreational activities................................................................... 11

Methodology ............................................................................................................................... 12

Data Sources and Searches .................................................................................................... 12

Study Selection ....................................................................................................................... 12

Review Process ....................................................................................................................... 12

Literature Review ........................................................................................................................ 13

Trails included in the literature review ...................................................................................... 13

Aquarobics .............................................................................................................................. 13

Benefits of Aquarobics for balance .................................................................................. 13

Risks of Aquarobics for balance ...................................................................................... 13

Cycling .................................................................................................................................... 14

Benefits of cycling for balance ......................................................................................... 14

Risks of cycling for balance ............................................................................................. 14

Dancing ................................................................................................................................... 14

Benefits of dancing for balance ....................................................................................... 14

Risks of dancing for balance ........................................................................................... 15

Exergaming ............................................................................................................................. 15

Benefits of Exergaming on balance ................................................................................. 15

Risks of exergaming on balance ..................................................................................... 16

Golf ........................................................................................................................................ 16


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Benefits of golf on balance .............................................................................................. 16

Risks of golf on balance .................................................................................................. 16

Lawn bowls ............................................................................................................................. 16

Benefits of lawn bowls on balance .................................................................................. 17

Risks of lawn bowls on balance ...................................................................................... 17

Lifeball ..................................................................................................................................... 17

Benefits of Lifeball on balance ........................................................................................ 17

Risks of Lifeball on balance............................................................................................. 17

Tai Chi ..................................................................................................................................... 18

Benefits of tai chi on balance .......................................................................................... 18

Risks of Tai Chi on balance............................................................................................. 19

Tennis ..................................................................................................................................... 19

Benefits of tennis on balance .......................................................................................... 19

Risks of tennis on balance .............................................................................................. 19

Walking ................................................................................................................................... 20

Benefits of walking on balance ........................................................................................ 20

Risks of walking on balance ............................................................................................ 20

Yoga ........................................................................................................................................ 21

Benefits of yoga on balance ............................................................................................ 21

Risks of yoga on balance ................................................................................................ 21

Recommendations ...................................................................................................................... 22

Limitations ................................................................................................................................... 23

Next Steps ................................................................................................................................... 24

Glossary ...................................................................................................................................... 25

References .................................................................................................................................. 27

Appendices ................................................................................................................................. 33

Appendix 1: Summary table of included trials (n=30) showing sample size, balance tests used, results, strengths, limitations and conclusions ......................................................................... 33


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Acknowledgements

Stay On Your Feet® would like to acknowledge the individuals, groups and organisations who

contributed their time and experience to producing the final document.

Name Position and organisation

Rachel Meade Evidence and Practice Coordinator, Falls Prevention Programs, ICCWA

Roisin Sweeney Project Assistant, Falls Prevention Programs, ICCWA

Siva Nagendra Volunteer, Falls Prevention Programs, ICCWA

Ailsa Dinnes Manager, Falls Prevention Programs, ICCWA

Emily Anderson Senior Coordinator, Falls Prevention Programs, ICCWA

Michael Atkinson Operations Manager, ICCWA

Dr Nicholas Waldron Clinical Lead, WA Health Falls Prevention Network

Falls Prevention Health Network Executive Advisory Group members


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Foreword

In Western Australia between 2008 and 2012 there were 73,509 hospitalisations due to falls (Department of Health Western Australia, 2015). With the risk of falling increasing with age and Australia’s ageing population, without intervention it is predicted that this number will grow. The impact that falls can have is vast as having a fall can bring about fear of falling, loss of confidence, emotional strain, reduced quality of life, social isolation and an increased risk of early death. There are also direct economic costs accompanying healthcare and indirect costs associated with the productivity lost from the individual or family care giver being unable to work. Due to the prevalence of falls within WA, an ageing population and the range of factors that can impact on an individual’s risk of experiencing a fall, falls prevention requires attention across the lifespan and a multidisciplinary approach. The Falls Prevention Model of Care 2014 (MoC), provides recommendations to achieve best practice across WA and includes the broad uptake of evidence-based exercise programs. However, the current evidence only examines limited programs and these may not suit all older adults. To be inclusive, the MoC supports increased uptake of physical activities that improve balance and are enjoyed by older people themselves. This report by Stay On Your Feet® provides a review of what is known about recreational activity, the benefits and includes the impact on balance and other falls risk factors. The Personal Choice Report outlines the benefits of existing popular, culturally and age appropriate recreational activities in increasing balance and preventing falls. I am confident that by increasing the awareness of the role that balance plays in falls prevention and encouraging older adults to participate in recreational activities; we can reduce the impact that falls are having on Western Australians.

Dr Nicholas Waldron

Clinical Lead, WA Health Falls Prevention Network

September 2015


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Executive Summary

There is strong evidence that participation in exercise programs that are based on balance

exercises, performed for 2-hours per week in an ongoing fashion is effective in preventing falls;

however there is a lack of research into the effect of different recreational activities in relation to

preventing falls in older adults.

The aim of this report is to compile and disseminate information on the benefit(s) of existing

popular, culturally and age appropriate recreational activities in increasing balance which may lead

to preventing falls. This report outlines the identified benefits and risks associated with aqua

aerobics, cycling, dancing, exergaming, golf, lawn bowls, Lifeball, tai chi, tennis, walking and yoga.

Of the recreational activities examined all were found to have positive effects on varying measures

of balance which supports that these activities may have a positive effect of reducing falls risk. Tai

chi was the only activity with direct evidence for preventing falls in high quality trials. The quality

and quantity of research for other activities was limited and comparison between different activities

was not possible, instead the current knowledge risks and additional benefits are described.

Although the finding are encouraging, broad recommendations for specific recreational activities

can’t be made, instead this information can be used to support appropriate and tailored physical

activity that is consistent with the individuals preferences for inclusion in a regular exercise regime.

Further research is required to explore the potential benefits and risks of different recreational

activities, helping to support the general population to adopt exercise behaviours that support good

health and wellbeing.


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Introduction

The Stay On Your Feet® program promotes that popular recreational activities for older adults,

such as lawn bowls and tai chi can be endorsed as an effective way to minimise the age-related

decline in balance and thus reduce the risk of falls.

This report collates findings from academic networks on the benefits of different activities for

preventing falls and maintaining good health, providing evidence that recreational activities can

improve balance and contribute to a reduced risk of falls in older people. The Personal Choice

Report will be available for access on the Stay On Your Feet® website to inform the community,

academic stakeholders and health professionals of initiatives including research, resource

allocation and promotions that reduce the risk of falls. By confirming with evidence which

recreational activities have the potential to contribute to preventing falls it provides the opportunity

for health professionals and community workers to refer their clients to recreational activities with

confidence.

Although the recreational activities outlined in this document can contribute to reducing an

individual’s risk of experiencing a fall, it is also important to factor in any potential risks associated

with the recreational activity. To assist the reader in recognising the potential risks to balance that

can result from participating in the activity; any risks identified in the sited research are included in

the activity summaries. In addition to this as every individual has their own unique characteristics it

is important to not only weigh up the benefits and risks listed in this document but also any risks

that may result due to the participant’s health status.

Epidemiology of falls

As people age, their risk of falling increases with global statistics showing 1 in 4 people over the

age of 60 and 1 in 3 over the age of 65 fall each year (World Health Organisation, 2007). Between

2008 and 2012 there were 73,509 hospitalisations due to falls in Western Australia (Department of

Health, 2015). In 2012 alone hospitalisations in Western Australia due to falls cost approximately

$117,957,168 (Department of Health, 2015).

In Western Australia between 2007 and 2011, there were 756 recorded deaths due to falls

(Department of Health, 2015). Of these, 45% (340) were males and 55% (416) were females.

Consequences of falls

Whilst the risk of falling increases with age, the outcomes of these falls also take on greater

significance. Although most falls produce no major injury, 5 - 15% of community dwelling older

adults who fall each year sustain a serious physical injury such as a hip fracture, head injury,

laceration or are psychologically affected (American Geriatrics Society and British Geriatrics

Society, 2011). Post-fall anxiety syndrome or fear of falling is a recognised consequence of falls. It

can result in self-imposed activity restrictions and loss of confidence in safe ambulation which

leads to further functional decline, depression, social isolation and placing an individual at higher

risk for another fall (Cumming, Salkeld, Thomas, & Szonyi, 2000; Tinetti, Mendes de Leon,

Doucette, & Baker, 1994).

The future impacts of falls

Australia’s population is ageing and it is predicted that 20% of Australians will be 65 years or older

by 2031 (Australian Institute of Health and Welfare, 2012). This means that, the total estimated

health cost attributable to falls-related injury could increase threefold to $1375 million by 2051

(Moller, 2003).


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Causes of falls

A review of 12 retrospective studies, involving 3,628 falls, cited the following most common causes for falls (Rubenstein & Josephson, 2002):

1. Accident/Environmental hazard, fall from bed – 31% 2. Balance impairments and gait disorders, weakness – 17% 3. Other Specified (i.e. arthritis, acute illness, medications or alcohol; pain) – 15% 4. Dizziness/Vertigo – 13% 5. Central nervous system disorder, syncope, drop attacks, epilepsy – 10% 6. Unknown – 5% 7. Confusion and cognitive impairment– 5% 8. Postural hypotension – 3% 9. Visual problems – 2%

Balance

Balance is the second most common cause of falls and can be defined as the ability to maintain

projection of a body’s centre of mass within manageable limits of the base of support or in transit to

a new base of support, as in walking (National Ageing Research Institute, 2006). Without

intervention trends indicate a considerable age-related decline in balance. Individuals aged around

70 years have close to normal balance scores, however there is a significant decline in balance

and greater variability past this age (Downs, Marquez, & Chiarelli, 2014). Fortunately, this decline

in balance is a modifiable risk factor for falls as by maintaining optimum balance longer into life it

reduces the risk of experiencing a fall.

Injury Control Council of Western Australia

ICCWA’s purpose is to advocate, collaborate and deliver programs to minimise harm from injury in

the community using evidence based practice.

Stay On Your Feet®

Stay On Your Feet® is WA’s falls prevention program for older adults living in the community. It

educates community members, health professionals and community workers about how to prevent

slips, trips and falls. Stay On Your Feet® is coordinated by the Injury Control Council of Western

Australia with the support of the Department of Health.

Stay On Your Feet® promotes how to keep active and alert through Move Improve Remove and

evidence informed programs for older adults. Move your body, improve your health, remove

hazards are three steps to keep active and alert to prevent slips, trips and falls.

Within each step there are a number of suggested actions which are based on contemporary falls

prevention evidence. Move Your Body consists of; Build Your Balance and Strengthen Your Legs.

The Personal Choice Report focuses specifically on Build Your Balance which addresses the

second most common cause of falls, impaired balance.


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Falls Prevention Programs

Current falls prevention programs

Due to the impact falls have on the community, there has been extensive randomised trial-based

research into exercise programs that can be used to safely prevent falls in older adults. The Otago

Exercise Program is one such program, with results indicating that the program resulted in a

reduction in falls and a reduction in the rate of injuries for both men and women, particularly for

participants aged 80 years and over who had fallen in the previous year (Sherrington et al. 2008).

The Stay Safe, Stay Active study is another example of an exercise intervention aimed at reducing

falls. Stay Safe, Stay Active utilised weekly structured group sessions of moderate intensity

exercise in both community and home settings, with results specifying that community dwelling

older adults who participated in this study over the one year period were 40% less likely to fall and

one-third of participants were less likely to suffer a fall-related injury compared to those who did not

receive this intervention (Barnett, Smith, Lord, Williams & Baumand, 2003).

The Stepping On Program is a multifaceted community based falls prevention program that

focuses on improving lower limb balance and strength, with the aim of improving fall self-efficacy

and reducing the incidence of falls among older adults aged 65 and over who had a fall in the

preceding year or have a fear of falling (Stevens & Sogolow, 2008). The stepping on intervention

group reported a 31% reduction in falls 12 months after the program completion, with secondary

analysis revealing that this program is particularly effective for men (p=0.003).

By integrating movements specifically prescribed to improve balance into everyday activities, the

Lifestyle Integrated Functional Exercise (LiFE) program aims to reduce the rate of falls in high risk

older adults living at home. After 12 months follow up, there was a 31% reduction in the rate of falls

and a 29% improvement in static balance for the LiFE participants compared with control

participants (Clemson, et al., 2012).

Ideal characteristics of a falls prevention exercise program

Falls Prevention research has moved towards identifying the specific elements or characteristics

which make exercise programs successful in falls prevention. Sherrington et al. (2008) conducted

a systematic review with meta-analysis on 44 studies and showed that the greatest relative effects

of exercise on fall rates were observed in programs that safely challenge balance (exercises that

modify the base of support, reduce upper limb support and involve movements of centre of mass)

and have a high total dose of exercise (at least two hours per week or greater than 50 hours over

the trial period).

These findings are supported by Arnold, Sran, and Harrison (2008); Clemson et al. (2012) and

Sherrington, Lord, and Close (2008) and are considered as current best practice recommendations

for falls prevention (see Table 1 below). More importantly, this information is crucial as it provides

detailed criteria against which other programs or in the case of this project, recreational activities

can be assessed and deemed efficacious in improving balance and reducing risk of falls.


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Table 1: Ideal characteristics of a falls prevention program

Category Characteristic

Static and Dynamic Balance Involves movement of Centre of Mass (COM)

Involves movement to limits of anterior and postural sway

Challenges limits of dynamic and static stability

Involves shifting body weight from foot to foot

Involves turning and changing direction

Reduces upper limb support

Reduces size of base of support

Involves multidirectional reaching

Neuromuscular Challenges hip extension Range of Motion (ROM)

Challenges gait speed

Requires gait speed

Requires fast reaction / response time

Involves activation of hip and ankle muscles

Sensorimotor Involves movement of head

Involved moving visual targets or field

FITTIP Task oriented

High total does of exercise (>2 hours / week)

Involves movement with high repetition, usually low load, and is

progressive

Not modular in organisational type

Adapted from “Effective exercise for the prevention of falls: A systematic review and meta-analysis” by

Sherrington, C. et al., 2008, Journal of the American Geriatrics Society, 56(12), 2234 – 2243.

doi:10.1111/j.1532-5415.2008.02014.x

The George Institute for International Health & Prince of Wales Medical Research Institute (2009)

investigated the characteristics of community based physical activity falls prevention programs.

Their findings supported those of Sherrington et al. (2008) but revealed a unique outcome. They

recommended ongoing balance-challenging exercise for at least 2 hours per week; however, only

25% of visited classes and programs met these recommendations. Most (28%) were providing a

high challenge to balance but failed to meet the recommended 2 hours exercise per week or were

short term. This finding highlights the current trend of minimal evidence being integrated into

practice and supports the need for more sustainable balance challenging activities that have a

higher dose per week.


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Recreational Activities

Benefits of recreational activities

There are several mental and social benefits associated with involvement in recreational exercise

including reduced stress, anxiety and depression (Schwarzenegger, Chrisman, & Coleman, 2005).

In providing opportunities for older adults to socialise, recreational exercise can also reduce

feelings of alienation and loneliness, and increase self-esteem and self-efficacy.

Exercise interventions incorporating balance exercises have long been considered a viable falls

prevention initiative due to their logical and universal approach (Cho, An, & Yoo, 2014). However

as exercise programs usually require the development of a personalised program and the use of

specialised equipment, recreational exercise can serve as a promising and feasible alternative for

the maintenance of balance in community dwelling older adults, due to its ability to be personalised

to the adult’s interests, instinctive, and often does not require expensive equipment (Hutchins,

2009).

Older adults’ participation in recreational activities

Despite the well-known benefits of recreational activities for older adults, participation rates in

these activities are low. Based on the 2006 General Social Survey only 56% of WA older adults

participated in some sport or physical activity in the 12 months prior to the survey (Australian

Bureau of Statistics, 2007). This is fairly similar to national trends (49% of Australian older adults).

Interestingly, participation rates did not vary significantly based on gender (Milligan, McCormack, &

Rosenberg, 2009). However participation rates have been shown to decline after the age of 65,

from 39% of those aged 55-64 years to only 23% of those aged over 65 years (Milligan,

McCormack, & Rosenberg, 2009).

Participation rates were also higher among older adults living in non-metropolitan areas of WA

compared to metropolitan areas, 69% and 58% respectively (Amonini, Braidwood, & Joyce H,

2011; Armstrong, Bauman, & Davies, 2000). Furthermore, participation rates were higher among

older adults born in Australia compared to those born overseas (in a country where the primary

language is English), 67% and 53% respectively. That being said, for older adults who were born

in countries where English is not the main language, participation rates were even lower (i.e. 49%)

(Australian Bureau of Statistics, 2011; Australian Institute of Health and Welfare, 2007).

Walking appears to be the most popular form of recreational exercise for WA older adults (32%),

followed by lawn bowls (7%) (Amonini et al., 2011). This is consistent with national trends (Merom,

Pye, et al., 2012). Surprisingly, cycling, tennis, tai chi and yoga were the least popular activities

that Australian older adults participated in, totalling less than 5% of activities (Amonini et al., 2011).

Australian older adults tend to only participate in one type of physical activity rather than a

combination of activities (Merom, Carmen, Kamalesh, & Adrian, 2012). Interestingly, most activities

were likely to be aerobic (e.g. walking, golf, cycling, racquet sports) as opposed to strength and

flexibility based activities proven to improve balance (e.g. tai chi, yoga, dancing) (Merom, Carmen,

Kamalesh, & Adrian, 2012).


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Methodology

Data Sources and Searches

A literature search was conducted in December 2014 using Google Scholar to identify studies that

looked into the effects of specific recreational activities on falls prevention. PubMed, Science Direct

and Prevention of Falls Network for Dissemination (ProFouND) databases were then used to

supplement the search.

Study Selection

Published randomised trials that were conducted in older people were reviewed if recreational

activity was the primary intervention being evaluated and the outcome was; balance test

measures, number of falls or rate of falls. Trials were ineligible if non recreational activity

interventions were a major component of the intervention under evaluation.

To determine eligibility of identified trials, the primary investigator independently scanned titles and

abstracts. If it was clear that there were less than two not fully randomised studies evaluating the

effect of a particular recreational activity (e.g. table tennis) on falls prevention, the study was

excluded on the basis that there must be sufficient valid evidence to warrant review and promotion

in the latter phases of this project. This resulted in only eleven recreational activities being included

within the final document. Whilst there was a search for studies investigating the effect of cultural

activities, such as Aboriginal dance on falls prevention, the current lack of relevant studies meant

that cultural activities were excluded from review. The full articles for the remaining titles were then

obtained.

All articles were then compared and contrasted to examine the benefits and risks that are

associated with each recreational activity in relation to reducing the risk of falls.

Review Process

After internal review of the draft document, the draft document was released for broad consultation

in July 2015 to allow for comments and feedback. Upon receiving this feedback edits were made to

the document before the document was finalised in September 2015. To view a complete list of the

document reviewers please refer to the acknowledgements on page five.


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Literature Review

Trails included in the literature review

In total, 30 trials and 11 different recreational activities were determined as appropriate for review.

These recreation activities include aquarobics, cycling, dancing, exergaming, golf, lawn bowls,

Lifeball, tai chi, tennis, walking and yoga. The included trials involved a total of 2,232 participants.

The majority of trials were conducted on older adults living in the community; one trial was

conducted on residents in high care residential facilities (i.e. nursing homes). Six trials included

only participants who could be defined as being at high risk of falls. Most of the recreational

activities evaluated in the trials (n = 25) were conducted under supervision, with fewer than 15

participants per instructor. In most of the programs, the frequency, intensity and duration of

recreational exercise was tailored to suit each individual participant (n = 25).

Characteristics and conclusions of the trials are summarised in appendix 1.

Aquarobics

Aquarobics has been used for a long time for treating musculoskeletal disorders; however it has

only recently been linked to falls prevention due to its positive effect on flexibility, muscle strength

and balance. The majority of individuals participating in aquarobics do so in an organised

aquarobics class, which can result in a higher cost than other recreational activities due to the

overall cost involving the class and admission to the pool.

Benefits of Aquarobics for balance

Kim and O’Sullivan (2013) investigated the effect of aqua exercise therapy on preventing falls in

the elderly. The results showed that after 12 weeks of aqua exercise therapy, balance was

improved by 30%. This result supports that of Devereux, Robertson and Briffa in 2005. Resende,

Rassi and Viana (2008) also evaluated the effect of a hydrotherapy program for balance, in relation

to the risk of falls in elderly women. They reported that after 12 weeks of hydrotherapy, there was

significant improvement in participants’ balance, as assessed using the Berg Balance scale

(p<0.001) and the Timed Up & Go test (p<0.001). There was also a reduction of the scores in a

scale of risk of falls.

These findings may be explained by the fact that water is viscous; it decelerates movement and

impedes falls, which prolongs the time available for regaining posture when the body is

unbalanced. Furthermore, floating acts as a support which can increase an older adult’s

confidence and reduce their fear of falling. In this manner, individuals or more specifically, older

adults can be challenged beyond their limits of stability without fear of consequences of falls that

would occur during land-based activities (Resende et al., 2008).

Risks of Aquarobics for balance

The literature included in this review did not identify any risk to balance and/or risk to falling whilst

participating in Aquarobics.

Benefits of aquarobics for balance:

Improves balance

Reduces the scale of falls risk factors

Reduces fear of falling


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Cycling

With over 50% of Australian older adults undertaking their physical activity in unstructured forms

and the majority preferring to exercise alone rather than in a group, activity that is individual-based,

such as cycling, poses a promising option for older adults who are able to ride a bicycle or are

already physically active. Most people cycle for leisure in an unstructured way, which bearing the

initial cost of purchasing a bicycle allows for minimal ongoing costs.

Benefits of cycling for balance

Although it is unknown if cycling prevents falls, there is some evidence to suggest that cycling is

associated with improved balance of older adults.

Rissel, Passmore, Mason and Merom (2013) conducted two pilot studies to examine the effect of

cycling on balance among older adults. Study one investigated whether age-related declines in

balance are moderated by cycling. Their results showed that participants who had cycled in the

last month reported significantly better results on dynamic balance measures of decision time and

reaction time, 13.4% and 18.6% respectively. Study two examined whether regular cycling can

improve balance. They reported that cycling at least one hour per week was associated with 4.8-

5.8% improvements in balance (decision time and response time) and timed single leg standing.

Overall, the results suggest that cycling has a positive impact on balance, over and above what is

gained through other physical activity.

Risks of cycling for balance


participating in cycling.

Dancing

Dancing is an instinctive type of exercise for many older adults as many have enjoyed music and

had positive experiences of dance earlier in their lives (Walls, 2012). Dancing does not require any

form of structured participation, however if participation is through a structured format participation

costs are comparative to other recreation activities.

Benefits of dancing for balance

Federici, Bellagamba, and Rocchi (2005) examined the efficacy of an exercise program based on

dance in improving balance in adults. Results showed that the exercise group had considerable

improvements in balance test results compared to the control group. Furthermore, da Silva Borges

et al. (2014) and Jeon et al. (2005) reported an increase in lower extremity strength and

significantly fewer falls post-test relative to pre-test (p<0.0001) in the dancing group after 12 weeks

of dancing in the form of foxtrot, waltz, rumba, swing, samba and bolero.

These findings could also be explained by the fact that dancing activates the basal ganglia,

responsible for motor control and learning, posture, coordination and speed of movement (Walls,

2012). In doing so, dancing preserves functional autonomy and balance, thus minimising the risk of

falls. Studies (McKinley et al., 2008; Walls, 2012) have also compared different forms of dancing

and revealed that Greek and Salsa dance had the greatest improvements in static and dynamic

balance compared to Aerobic dance.

Benefits of cycling for balance:

Improves balance

Improves reaction time


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Apart from the balance-related benefits of dancing, 17 out of the 20 participants in the Federici et

al. (2005) study exercise group reported great or moderate satisfaction with the dance activity. This

psychosocial benefit has important implications as satisfaction is directly correlated to adherence

to exercise (Shigematsu et al., 2002). However, the majority of the studies were conducted using

only female participants. As such, it is still somewhat unclear whether older men can derive the

same benefits from dancing as do older women (Eyigor, Karapolat, Durmaz, Ibisoglu, & Cakir,

2009; Hopkins, Murrah, Hoeger, & Rhodes, 1990; Kim, June, & Song, 2003; Young, Weeks, &

Beck, 2007). Moreover, dance exercise classes tend to be modular in organisation and often rely

on learning a fixed sequence of steps and do not always increase in intensity or complexity, thus

limiting the amount of variety and challenge. This could increase attrition rates and poses an issue

worthy of consideration when recommending this form of activity to older adults.

Risks of dancing for balance


participating in dancing.

Exergaming

In recent years, games consoles such as Nintendo Wii and Xbox have become increasingly popular among the older adult population, particularly in nursing homes and assisted-living communities. Research has been conducted to discover the potential of exergames for balance rehabilitation and in reducing the risk of falls in older adults due to their accessibility, affordability, its ease of use and potential for in home use (Agmon et. al, 2011).

Benefits of Exergaming on balance

Brumels, Blasius, Cortright, Oumedian, and Solberg reported in 2008 that participation in Nintendo

Wii Fit games significantly reduced anterior and posterior postural sway, and a reduced deviation

from the centre of pressure, all indicating an improvement in balance. More specifically, being task

oriented and a repetitive form of training, Wii games induce neuroplasticity and thus, reduce the

risk of accidental falls and fall-related injuries (Prosperini et al., 2014).

Agmon, Perry, Phelan, Demiris, and Nguyen (2011) determined the safety and feasibility of using

Nintendo’s Wii Fit exergames to improve balance in older adults. With only 2 of the games

requiring modification for safety reasons, there was an improvement in Berg Balance scores from

49 (2.1) points to 53 (1.8) points after three months of this intervention. This finding is supported by

Gardner (2011) and Clark and Kramer (2009). However this improvement by Agmon, Perry,

Phelan, Demiris, and Nguyen may be spurious given the small sample size of seven participants

and lack of control group. That being said, the qualitative feedback from Clark and Kramer

reporting that participants rated high enjoyment immediately after exergame play and expressed

notable improvements in balance in relation to their daily activities suggests that the changes as

measured by the Berg Balance scale may be accurate. This has important implications as older

adults are more likely to adhere to participating in a recreational activity for the long term if

motivation and level of enjoyment are high. The use of exergames as balance training tools is

growing and will continue to grow with the developments of sensor technology (Van Diest, Lamoth,

Stegenga, Verkerke & Postema, 2013).

Benefits of dancing on balance:

Improves static and dynamic balance

Improves lower extremity strength

Preserves functional autonomy


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Risks of exergaming on balance


participating in exergaming.

Golf

In a well-executed golf-swing, there are certain requirements that must be reached. That is, golfers

must maintain good balance and precise postural control of the head and body in relation to space

and to the limb, as well as timely coordination of their muscle activities (Tsang and Hui-Chan,

2004). Due to the equipment and playing surface requirements for golf it can be an expensive

recreational activity, particularly when starting to play.

Benefits of golf on balance

Tsang and Hui-Chan (2004) demonstrated that experienced elderly golfers had improved knee

joint proprioceptive acuity and limits of dynamic stability, when compared with the elderly control

participants. These findings have important implications as it suggests that golf could minimise the

age-related decline in these specific sensorimotor functions. Golfing requires golfers to shift their

body weight in a smooth and coordinated manner, which may potentially enhance the directional

control of their leaning trajectory.

Risks of golf on balance


participating in golf.

Lawn bowls

Lawn bowls is very popular among older adults and is highly recommended for this age group as it

is low impact and usually occurs in a social and supportive atmosphere. However, the kind of

balance training that is provided by lawn bowls has not been specifically researched in regards to

reducing the risk of falls among older people.

Lawn bowls clubs cater for one off participants and ongoing members which can vary the costs

associated with participating. Most lawn bowl clubs offer one off participation fees for irregular

participants providing an affordable option, which includes the costs associated with using the

green and the rent of bowls for the session. If participating at a higher frequency most people opt

to become a member of a club and purchase their own bowls.

Benefits of exergaming on balance:

Reduces anterior and posterior sway

Reduces deviation from the centre of pressure

Induces neuroplasticity

Benefits of golf on balance:

Maintains balance

Improves coordination of muscle activities

Minimises the overall age-related decline in sensorimotor functions

Enhances control of leaning trajectory


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Benefits of lawn bowls on balance

Brooke-Wavell and Cooling (2009) compared fall-risk factors between older (60-75 year old) women who regularly participate in lawn bowls and controls. Regular bowlers were shown to have significantly lower timed-up & go test times and less sway while standing on a compliant surface. As such, long term participation in lawn bowls could help prevent frailty. One simplistic explanation for this finding is that lawn bowls maintains major joint movements and in doing so, prevents weakness and atrophy of the core and lower limb muscles that control balance (Mcgrath & Cassell, 2002).

Risks of lawn bowls on balance


participating in lawn bowls.

Lifeball

While most ball games promote physical activity, they may not be appropriate for older adults due

to the injury risk (Barnett, Green, van Beurden, Campbell and Radvan 2009). Hence, the invention

of Lifeball, a team-based option for older adults that is played at walking pace with ball throwing

similar to netball and basketball. This game has gained increasing popularity with over 1000 older

adults participating in Lifeball per week in 73 groups in four Australian states. Lifeball has been

developed for older adults and acknowledging that many older adults have limited disposable

income most Lifeball games are run for free by the local shire or community group, while other

require a small fee to participate.

Benefits of Lifeball on balance

As Lifeball was developed to provide an opportunity for older adults to participate in a team

recreational activity that was played at a walking pace, in addition to participants gaining the

benefits associated with walking, Lifeball has the potential for participants to gain the benefits

associated with participating in a team based activity. The stop/start nature of Lifeball enables the

participants to build their static and dynamic balance in a fun environment (Barnett, Green, van

Beurden, Campbell and Radvan, 2009).

Due to the format of the game the reduced injury risk associated with the game encourages older

adults to participate and gain the health benefits associated with participating without the high level

of risk that is associated with other recreational activities.

Risks of Lifeball on balance

That being said, Barnett, Green, van Beurden, Campbell and Radvan (2009) showed that this

game is not risk-free as falls do occur during game participation. Falls are a particularly common

cause of recreation related injury which highly influenced the development of Lifeball. Falls that

have occurred while participating in Lifeball have been linked to the individual not adhering to the

Lifeball rules and recommendations.

Furthermore, this game was developed on the premise that walking is a popular exercise of choice

for older adults. In light of recent evidence suggesting that walking is not ideal for falls prevention,

due to the benefits associated with participating in Lifeball and the reduced injury risk when

Benefits of lawn bowls on balance:

Supports the maintenance of major joint movements

Prevents weakness in the core and lower limb muscles that control balance

Less sway when standing on a compliant surface


September 2015

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compared to other team recreational activities, this novel ball game should be recommended with

caution and when participating the rules and recommendations should be followed.

Tai Chi

It is common for elderly fallers to have reduced proprioception in their lower limbs (Lord, Rogers, Howland, and Fitzpatrick, 1999). Participating in tai chi requires the individual to shift their body weight to different target positions in a smooth and coordinated manner. In order for participants to maintain their centre of mass within their base of support their balance control systems are challenged (Taylor et al., 2012). The Falls Prevention Model of Care acknowledges that systematic reviews have identified that tai chi can reduce falls by 37% (Department of Health, 2014).

When economically evaluated, tai chi serves as a feasible option to prevent falls, which has

important implications given the predicted increased cost of falls in the future.

Benefits of tai chi on balance

Wolf et al. (1996) was the first large study to assess the effect of a 15 week program of tai chi

classes that used 10 simplified movements on community dwelling older adults. Among the tai chi

class participants, after four months follow up, the risk of multiple falls was reduced by 47.5%.

Moreover, participants reported that after the study, they were better able to stop themselves from

falling by using their environment and appropriate body manoeuvres. Thus, it can be supported

that a moderate tai chi intervention can impact favourable on defined sensorimotor indices of

frailty, such as balance, as well as upon the occurrence of falls. A Cochran review into

interventions for preventing falls in older people living in the community found that tai chi classes

were the only single exercise intervention effective in reducing the risk of falling (Gillespie, 2009).

The review also concluded that tai chi as a group exercise is less effective in people at higher risk

of falling.

Li, Harmer, Fisher, and Mcauley (2004) also compared the effectiveness of a six month classical

24-Form Yang style Tai Chi on 70 year old older adults. Their results revealed that participants in

the tai chi classes had fewer falls, lower proportions of fallers and fewer fall-related injuries than

the control group. Furthermore, their risk of falling was 55% lower than that of the control group.

This trend is supported by Low, Ang, Goh, and Chew (2009) who included 24-Form Yang style Tai

Chi, Sun-style Tai Chi and synthesized forms of Tai Chi in their study, and Taylor et. al (2012)

which focused on Sun-style Tai Chi.

A study conducted by Voukelatos, et.al. in 2007 which included Sun-style Tai Chi (83% of included

Tai Chi programs were Sun-style Tai Chi), Yang-style Tai Chi and a mixture of several styles,

supports tai chi as an effective and sustainable public health intervention for falls prevention

amongst older people living in the community, with results indicating that participants risk of

multiple falls decreased by approximately 70%.

Benefits of Lifeball on balance:

Improves postural control system

Builds static and dynamic balance

Improves fitness Risks of Lifeball on balance:

Participating in a team requires awareness of other peoples movements

Potential to focus too much on the ball and the competition rather than balance


September 2015

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As evident in the above literature, research into the benefits of tai chi has included a range of

styles of tai chi. Each style includes unique characteristics and therefore the results of each

research study is influenced by the style of tai chi used in the study.

Risks of Tai Chi on balance


participating in tai chi.

Tennis

Extensive research has been completed relating to the numerous health benefits of tennis for

individuals at all life stages, with results supporting participating in tennis as in the majority of the

research the benefits outweighed the risks. Contrasting this, there is a lack of literature

investigating the balance related benefits experienced through tennis.

As tennis requires personal equipment there are one off expenses involved and ongoing expenses

due to the hiring of a court. However as tennis provides the opportunity to play socially or in a club

overall it is economically sustainable (Groppel & DiNubile, 2009).

Benefits of tennis on balance

Studies have suggested that tennis improves dynamic balance as it requires total control of one’s

body even while running at top speed (Groppel & DiNubile, 2009; Marks, 2006). Furthermore,

cognitive alertness and joint proprioception has been shown to be enhanced from engaging in

tennis. More importantly, these skills or abilities can be easily translated to everyday life, thus

allowing older adults to reduce their risk of falls and live independently well into their 90’s. As the

risk of injury associated with tennis is comparatively lower than other sports, it is safe to

recommend tennis to older adults in an attempt to improve balance and reduce their risk of falls.

Risks of tennis on balance

Despite tennis providing benefits to balance, there are a range of injuries that can occur while

playing tennis, particularly as a result of lifelong participation, which can then pose as a risk to the

individuals balance. Injuries to the wrist, elbow and Achilles tendon promote osteoarthritis,

tendonitis, sprains, strains and occasional fractures which can not only reduce the individuals

balance but are also health concerns (Marks, 2006).

Benefits of tai chi on balance:

Maintains centre of mass within the base of support

Develops joint proprioception in lower limbs

Improves overall balance

Reduces risk of falling

Benefits of tennis on balance:

Improves dynamic balance

Develops joint proprioception

Enhances cognitive alertness Risks of tennis on balance:

Injuries to the wrist, elbow and Achilles tendon which can promote osteoarthritis, tendonitis, sprains, strains and fractures


September 2015

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Walking

As was previously mentioned, the majority of WA older adults (32%) choose walking as their

predominant form of exercise. While walking at, or above, 3-4 km per hour confers health benefits,

its role in falls prevention remains unclear (Voukelatos et al., 2011).

Falls are not the only important outcome for exercise trials in elderly populations, as studies have

shown that walking programs exert great benefits on fitness. As such, if falls prevention is the

primary aim, walking programs should be included only if they are in addition to other activities

more beneficial in improving balance and reducing falls risk (Asikainen et al., 2006).

Walking is the cheapest recreational activity available as it only requires supportive footwear and a safe walking environment.

Benefits of walking on balance

A 15 week walking program showed no significant effect on balance among sedentary, post-

menopausal women (Asikainen et al., 2006). However, fractionating walking into two daily

sessions was shown to be more feasible than continuous walking. The overall results of the study

were influenced by the fact that over 50% of the participants reached a maximum score in the

baseline balance testing which might have decreased the possibility to detect a real training effect.

Conversely, a study which compared the effectiveness of three different balance training

programs, including walking in women aged 50-75 years, found that all three programs improved

dynamic balance, but walking had a more significant effect on static balance (Clary, Barnes,

Bemben, Knehans, & Bemben, 2006).

Risks of walking on balance

Recent research (Murphy, Nevill, Murtagh, & Holder, 2007; Sherrington et al., 2008) has revealed

that compared to exercise programs that involve walking, programs that exclude walking are

beneficial to reducing the risk of falls. This may be due to the fact that there is increased exposure

to risk with walking, although published trials do not indicate that many falls occurred when

participants were undertaking walking programs. An alternative explanation could be that walking

utilises time that could otherwise be allocated to high level balance training.

Due to walking requiring a range of processes, including; initiating and terminating gait, changing

direction, adjusting stride length and adjusting step height walking highly challenges the postural

control system. The walker must actively consider a range of factors while walking, which if not

considered and actioned appropriately the individual is at risk of experiencing a fall.

Benefits of walking on balance:

Improves dynamic balance

Improves static balance

Develops fitness

Risks of walking on balance:

Exposure to risk

Challenges the postural control system


September 2015

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Yoga

Over the past decade, the use of yoga to prevent falls and reduce the risk of falling in community

dwelling older adults has gained popularity (Kelley, 2013). Yoga practice has been shown to

specifically target and improve factors such as free joint mobility, appropriate timing and intensity

of muscle action, as well as normal sensory input that promote normal balance (Woollacott,

Shumway-Cook, & Nashner, 1982). The only form of equipment associated with yoga is a yoga

mat, meaning that yoga can be completed in an individual’s home with minimal expenses (Kelley,

2013). If the individual wants to participate in a yoga class the majority have admission costs

associated, however most are comparative to other recreational activities.

Benefits of yoga on balance

Zettergen, Viverito, and Lubeski (2011) conducted a pilot study with 16 participants aged 79-88.

After eight weeks of yoga, there was a statistically significant improvement on scores on balance

tests, revealing a reduced risk of falling (t=4.51; p<0.003). Brown, Koziol, and Lotz (2007) and a

pilot study conducted by Schmid, Van Puymbroeck, and Koceja (2010) support this trend as well,

with a 4% increase in static balance. Overall, participants in the yoga group reported feeling

steadier. The effect of yoga on fear of falling has also been examined. After 12 weeks of yoga,

participants reported a 6% decrease in fear of falling (Schmid, Van Puymbroeck, and Koceja,

2010).

DiBenedetto, Innes, Taylor, Rodeheaver, and Boxer (2005) evaluated the effects of yoga on gait

speed and hip extension. Although the authors of this study did not directly measure falls or falls

risk, improving gait speed and hip extension range of motion has been shown to reduce risk of

falling. As such, after eight weeks of yoga, there was a noticeable improvement in hip extension

range of motion but a non-significant increase in self-selected gait speed.

Furthermore, the importance and significant improvements in balance and fall risk associated with

incorporating specific poses into a yoga program has been researched (Brown et al., 2007;

Zettergen, Moriarty, & Zabel, 2006; Zettergen et al., 2011). More specifically, sitting and standing

positions have been shown to improve Berg Balance Scale scores and dynamic balance.

Risks of yoga on balance


participating in yoga.

Benefits of yoga on balance:

Improves static balance

Decreases fear of falling

Improves hip extension range of motion


September 2015

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Recommendations

This report has identified several gaps that warrant further attention.

Overall the literature search did not identify a large amount of research into the role that

recreational activities can have in falls prevention. As identified throughout this literature search,

the research shows a positive link that many recreational activities improve falls risk factors

including balance, flexibility and fear of falling. This is encouraging and further highlighting the

need research could determine if this leads to the prevention of falls.

Despite the research indicating that recreational activities have the potential to decrease an

individual’s falls risk, there is no consensus on whether older adults should be encouraged to

engage in multiple recreational activities or a single activity to elicit falls prevention benefits. Also

the ideal frequency, intensity and length of participation have not been established. Future

research into these areas would allow guidelines to be produced surrounding participating in

recreational activities as a falls prevention measure.

When deciding what type of recreational activity to become involved in an individual’s previous

experiences, preferences and views of the activity have a significant influence on what activity is

chosen. Despite this there is a current lack of evidence in the literature around the importance of

implementing strategies that adopt a person-centred approach to falls prevention. Research into

the importance of considering the impact that personal factors have on participation in recreational

activities and potential barriers /enablers to participation will support the development of a rounded

falls prevention intervention.

Research sited throughout this report suggests the importance of maintaining optimal balance

throughout the lifespan to aid in improving balance later in life. However there is minimal evidence

to support a hypothesis that participating in recreational activities in middle age can prevent falls in

older age. Despite the challenging longitudinal requirements of this type of study, the results that it

could produce would directly impact on falls prevention interventions.

This literature search identified no studies that specifically investigated the effectiveness of

recreational activities for falls prevention in culturally and linguistically diverse communities,

Indigenous populations or research into cultural activities for falls prevention, such as Aboriginal

dance. Further research into the benefits and risks of participating in recreational activities for

population subgroups would provide additional support for health professionals and community

workers when weighing up the benefits and risks associated with each recreational activity.

The research studies included within this literature search have used a variety of assessment tools

during their research which makes the comparison of results between the studies challenging. A

study into the benefits of recreational activities for balance that measures each activity using the

same criteria and assessment tools would allow for a valid comparison between the recreational

activities.


September 2015

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Limitations

All analysis conducted throughout this literature search was from a falls prevention perspective and

therefore does not consider any other factors that impact on the benefits and risks of participating

in the recreation activity.

The inclusion criteria for the trials only related to the purpose of the trial, excluding other criteria

such as the methodology. The lack of exclusion criteria surrounding the methodology of the trials

limited the opportunities to compare the research as the; assessment tools, sample size, duration

of the trial, criteria for participant inclusion and selection pool varied between the trials included in

this literature search.

Following the collection and filtering of the research, recreation activities were included in this

literature search if at least two fully randomised studies were retrieved relating to the recreational

activity. Therefore the eleven activities included in this trial are not necessarily the best recreational

activities for minimising the age-related decline in balance; rather that there is a lack of evidence

supporting the benefits of the recreational activities excluded from this literature search.

Studies included in this literature search focus on gait and stability when measuring balance.

However the vestibular system, somatosensory system and vision also contribute to an individual’s

balance. By not recognising the role that these factors have on balance it does not provide a

complete analysis of the role that recreational activities can have on improving an individual’s

balance.


September 2015

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Next Steps

This document is available for public access on the Stay On Your Feet® website to provide support

for health professionals and community workers when referring their clients to recreation activities

and for community members when deciding what recreational activity to participate in.

This literature search has identified a range of areas that warrant additional research to provide

further guidance to community members and health professionals on the potential benefits and

risks of recreational activity for minimising the decline in balance that can occur with ageing and

thus reducing the risk of falls.

If you require further information regarding this document please contact the team from Stay On

Your Feet® on [email protected] or 1300 30 35 40.

mailto:[email protected]


September 2015

Page 25

Glossary

Term Definition

Alternate step test measures lateral stability by timing the duration taken to alternatively place

the left and right foot eight times onto a step 18cm high

Ambulation the ability to walk independently from place to place with or without an

assistive device

Arterial sway rhythmic movement backwards and forwards

Atrophy gradual decrease in a body part or tissue

Berg Balance test assesses performance in 14 functional subtests to measure balance

among people with impaired balance.

CaLD communities Culturally and linguistically diverse communities

Community

dwelling

residing in private housing within the community

Dynamic stability the ability to return to a previously established steady state

Fall ‘Inadvertently coming to rest on the ground, floor or other lower level,

excluding intentional change in position to rest in furniture, wall or other

objects’ (Gillespie, 2009).

Falls Risk for Older

People – Com tool

covering 13 risk factors this falls risk assessment tool includes 26

questions with either dichotomous (0-1) or ordinal (0-3) scoring, with a

score higher than 18 indicating a high risk of falls.

Frailty a clinical term that describes the presence of multisystem impairment and

expanding vulnerability (Rockwood, 2005).

Gait a manner of walking

Hospitalisations total number of admissions to hospital

Health

Professional

a person employed in a field of health in a clinical, allied health or

population-based context. (Fransen, 2007).

ICCWA Injury Control Council of Western Australia

Intervention an action that attempts to modify the outcome

Literature search methodical search through published literature to identify relevant and

validated references relating to a particular topic

Meta-analysis statistical technique for combining findings from different studies in the

hope of identifying patterns among the studies


September 2015

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Term Definition

Modifiable risk

factor

conditions that increase your risk of developing a disease where methods

can be taken to change them

Neuroplasticity the ability for the brain to restructure itself

Older adult Non-Aboriginal person aged 60 years or older; or an Aboriginal person

aged 45 years or older

Person-centred places the individual at the centre of the approach

Postural sway rhythmic movement side to side

Practitioner an individual who practices a skilled profession or occupation

Randomised trial a study where participants are randomly assigned to different interventions

Range of motion the movement potential of a specific joint or body part

Recreational

activities

activities that are participated in for leisure that are fun, cognitive and/or

physical

Static stability the ability to maintain upright equilibrium at rest

Timed Up & Go test provide a global indication of steadiness by timing the duration taken for

the subject to stand, walk 3 meters, turn around and walk back to the chair

and sit down

WHO World Health Organisation


September 2015

Page 27

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Appendices

Appendix 1: Summary table of included trials (n=30) showing sample size, balance tests used, results, strengths, limitations and conclusions

Activity Reference

Method Age N Gender Tests Other Criteria

Results Strengths Limitations Conclusion

Aquarobics Devereaux et

al. (2005)

50 >65

Women

Diagnosis of

Osteopenia/

Osteoporosis

Step test.

2 x 1 hour/week

for 10 weeks

Mean between group

differences in balance

1.7 (0.9 to 2.6) and 2.1

(1.1 to 3.1) steps on

the left and right sides

respectively

Offers plausible

explanation behind

benefits of water

based activity on

balance.

Relative short term

duration of study

Potential sampling

bias during

recruitment process

Not double blinded

trial

Water-based

exercise

produced

significant

changes in

balance in this

group of

community-

dwelling women

Aquarobics Resende et

al. (2008)

25 72.60 ± 7.11

Women

Berg Balance

Scale; Timed Up

& Go.

2 x 40min

sessions/week

for 12 weeks

Improvement in Berg

Balance scale scores

(p<0.001), Timed Up &

Go test (p<0.001),

reduction of the scores

in a scale of risk of

falls (p<0.001).

Three distinct

phases with

specific session

timelines within

each, which

allowed for

adaption to

aquarobics

Low sensitivity of

Berg Balance Scale

affects ability to

predict risk of falls

Small sample size

No control group

This hydrotherapy

program for

balance gave rise

to an increase in

balance and a

possible reduction

in the risk of falls

among these

aged women


September 2015

Page 34

Activity Reference



Aquarobics Kim &

O’Sullivan

(2013)

15 65-77

Women

1hr 3 times a

week

Whole body dual

energy X-ray

absorptiometry

Cybex

Balance (s)

Expt 2.41

±2.2

9

3.14

±1.5

Cont 6.8±

4.71

4.77

±3.8

5

Considered

biomechanical and

physiological

factors affecting

gait

Small sample size

Gender imbalance

Only those with

high bone density

were included

therefore not

representative of

older female

population.

Aqua aerobic

therapy is an

effective exercise

method for

training older

adults to reduce

their risk of falling

Cycling Rissel et al

(2013)

43

44-79

Cycled for

preceding

month

Choice Stepping

Reaction Time

test

Leg strength test

Timed single leg

standing

13.4% (p=0.008) and

18.6% (p=0.050)

improvement in

decision time and

reaction time

respectively

Pilot studies

Range of tests

completed

Small sample size

Lack of comparison

group

Cycling by healthy

older adults

appears

promising for

improving risk

factors for falls

18

49 - 72 Same as above

1 hour / week for

12 weeks

4.8 – 5.8% (0.031

<p<0.058)

improvements in

decision time and

response time and

timed single leg

standing


September 2015

Page 35

Activity Reference



Dancing Frederici et

al. (2005)

40 58-68 Sit up and go

balance tests

Significant

improvement in

balance post dancing

intervention.

17/20 participants in

dancing group

reported great or

moderate satisfaction

with dance activity.

3 month

intervention

Revealed

interesting

psychosocial

benefits of dancing

Short intervention

Lack of follow up

Small age range

Physical activity

based on dance

may improve

balance and be

useful tool in

reducing risk of

falling in the

elderly.

Dancing Shigematsu

et al. (2002)

38 72-87

Women

Dancing for 60

minutes 3

times a week

for 12 weeks

Single leg

balance with

eyes

open/closed,

functional reach,

3 minute walking

distance.

Significant

improvements in single

leg balance with eyes

open and closed

(p=0.03), functional

reach (p=0.01) and 3

min walk (p=0.03)

Simple tests used

to measure main

outcomes

Lack of measures

of falls or number of

participants who fell

Short intervention

Lack of follow up

Dance based

aerobic exercises

designed

specifically for

women can

improve selected

components of

balance and

locomotion,

thereby

attenuating risk of

falls


September 2015

Page 36

Activity Reference



Dancing Gomes da

Silva Borges

et al. (2013)

59 60-76

Sedentary

Residents of

long stay

institutions

Ballroom

dancing 3 x 50

mins sessions

on alternate

days of the

week for 12

weeks

Lizard

stabilometric

and

posturometric

platform

Participants in the

dancing group

reported reduction in

lower limb weight

distribution and also

experienced

significantly fewer falls

post test relative to pre

test (p<0.0001). This

improvement not

observed in control

group.

Specified type of

dancing and dance

moves

High reliability of

platform method.

Lack of blinding

assessment.

Short intervention

Lack of follow up

Ballroom dancing

can be used to

improve balance

for elderly people

living in long term

institutions.

Dancing McKinley et

al. (2008)

30 62-91 Activity specific

Balance

Confidence

Scale and sit-to-

stand.

Two hours of

tango dancing

two times a

week for 10

weeks

Two way repeated

measures ANOVAs

indicated main effect

for time on all

measures (p<0.01) for

tango dancing group.

Strict inclusion and

exclusion criteria

lead to a similar

sample group

Preliminary results

Small sample size

Short intervention.

Tango dancing

may elicit

improvements in

balance skills in

elderly at risk of

falls


September 2015

Page 37

Activity Reference



Dancing Walls (2013) 4 RCT’s that

met inclusion

criteria

Dynamic and

static balance

measures used

Statistically significant

improvements in

dynamic (effect

size=0.69) and static

balance (effect

size=0.29) measures

based on fixed effect

model.

RCT and quasi

experimental

Poor quality RCT’s

No long term follow

up

Limited databases

utilised

Dance improves

balance in healthy

elderly adults

compared to

usual activities

Dancing Keogh et al.

(2009)

18 15 training and

3 cross

sectional

studies that

met inclusion

criteria

Body

composition,

VO2max, sit to

stand, postural

stability,

dynamic balance

and gait speed

measures were

used

Grade B: elderly can

improve their aerobic

power, strength,

balance, lower body

muscle endurance and

gait through dancing.

Grade C: dancing

might improve older

adults’ bone mineral

density as well as

reduce prevalence of

falls

First to review

physical benefits of

dancing for healthy

older adults

Small number of

studies

Lack of variety of

dance forms used

in the studies

Predominance of

female participants

in studies

Dancing has an

effect on balance

and falls

prevalence in the

elderly population.


September 2015

Page 38

Activity Reference



Exergaming Agmon et al.

(2011)

7 84 years old

Existing

impaired

balance

Care

retirement

communities

30 mins 3

times a week

for 3 months

Berg Balance

scores

4m timed walk

test

Physical activity

enjoyment scale

4 different

exergames-

basic step,

soccer heading,

ski slalom, table

tilt

Berg balance scores

increased from 49 to

53 points (p=0.017).

Walking speed

increased from 1.04 to

1.33m/s (p=0.018)

Higher rating of

enjoyment immediately

after exergame play.

Participants

received

individualised

instructions during

at least five home

visits.

Played four

exergames in their

homes for at least

30 minutes 3 times

a week for 3

months and

received weekly

telephone follow-

up.

Excluded large

number of

prospective

participants if they

had chronic

conditions or

deficits.

Optimal training

dose could not be

determined as

duration and

frequency of game

play was

inaccessible from

console

Lack of control

group

Use of Wii-Fit for

limited supervised

balance training

at home was a

safe and feasible

option to promote

health in older

adult populations.


September 2015

Page 39

Activity Reference



Exergaming Clark &

Kraemer

(2009)

1 89 years old

Diagnosed

with

unspecified

balance

disorder and

history of falls

Berg Balance

scores

Dynamic Gait

Index

Timed Up and

Go test

Nintendo Wii

bowling for 6

one hour

sessions

BBS improved by 5

points

DGI improved by 2

points

TUG improved from

14.9 to 10.5 sec

Accessible

resource

Required minimal

prompts from the

supervisor once the

technique was

mastered

The action required

the vestibular

system to register

linear acceleration

and changes in

gravitational force

Use of only one

individual.

Self-reported

measures

Nintendo Wii

bowling

simulation may

have decreased

fall risk

Exergaming Prosperini et

al. (2014)

27 Multiple

Sclerosis

patients

Diffusion tensor

imaging MRI

technique

12 week

intervention

using Wii

balance board

based visual

feedback

training

Task oriented and

repetitive training, as

in Wii balance board,

aimed at managing a

specific symptom is

highly efective and

induces brain

plasticity.

One of the first

studies to

determine the

mechanism behind

Wii games efficacy

for falls prevention.

Use of non-

conventional DTI

technique allowed

detailed analysis of

white matter tracts.

Short intervention

period

Lack of follow up

Use of clinical

population

Wii balance board

appears to show

favourable

changes in brain

connections

associated with

balance and

movement


September 2015

Page 40

Activity Reference



Exergaming Brumels et

al. (2008)

25 18-24 Star Excursion

balance testing

and force plate

data.

Wii Fit 3

times/week for 4

weeks

Postural sway

reduction for average

deviation on the y axis

observed (p=0.043).

First to examine

efficacy of video

game based

balance programs

Age group

Lack of follow up

Short intervention

period

Safe to prescribe

Wii Fit as a way to

improve physical

performance and

patient

compliance when

balance

improvement is

clinical treatment

goal


September 2015

Page 41

Activity Reference



Golf Tsang & Hui-

Chan (2004)

47 Experienced

tai chi

practitioners

(>1.5

hours/week for

past 3 years)

Experienced

golfers (>1.5

hours/week for

past 3 years)

Healthy elderly

subjects

Young

university

students

All males

Passive knee

joint

repositioning

test

Limits of stability

test

Tai chi:

Absolute angle error =

1.7 ± 1.3. Reaction

time = 0.8 ± 0.1

(p<0.0001)

Golfers:



time = 0.8 ± 0.2

(p<0.001)

Healthy elderly:



time = 1.0 ± 0.3

(p<0.001)

Young students:



time = 0.5 ± 0.1

(p<0.001)

Considered

different abilities

Thorough

examination of joint

flexibility

Exclusion criteria

Small sample size

in each group

Gender imbalance

Cross-sectional

design

Both experienced

tai chi

practitioners and

golfers had

improved joint

proprioceptive

acuity and

dynamic standing

balance control,

despite the known

ageing effects in

these specific

sensorimotor

functions.


September 2015

Page 42

Activity Reference



Lawn Bowls Brooke-

Wavell &

Cooling

(2009)

74 60-75

Women

Timed up and go

scores

Postural stability

Lower timed-up & go

test times and less

sway while standing

on a compliant surface

Regular bowlers

and control

participants were

similar in regard to

mean age, height,

and weight

Small sample size

Lack of follow up

Gender imbalance

Long term

participation in

lawn bowls could

help prevent

frailty

Lifeball Barnett et al.

(2009)

284 40-96;

238/284

Women

Self-reported

surveys

20 participants (7.6%)

had a Lifeball fall

equating to a fall rate

of 2.8 per 1000 hours

of participation

Sample from a

large diverse

geographical

region; has

frequency and

duration of play

(1.25 hours)

Self-report bias

Intensity of play not

documented

Lifeball not risk-

free as falls do

occur during

game

participation

Tai Chi Li et al.

(2005)

256 70-92

Healthy,

physically

inactive

Berg Balance

Scale

Dynamic Gait

Index

Functional reach

60 mins 3

times/week for

six months

For tai chi group, post

intervention, risk of

falls was 55% lower

than that of the control

group.

Also significant

improvements in all

measures of functional

balance, physical

performance and

reduced fear of falling.

Appropriate

inclusion criteria

Experienced

trainers running the

activities

Statistical analysis

of the results

Structured sessions

Possibility of

experimenter bias

as not double blind

protocol

Tests for limits of

stability and

muscular strength

not used, thus

elucidating other

possible

mechanisms by

which tai chi

improves balance

Improved

functional balance

through tai chi is

associated with

subsequent

reductions in fall

frequency in older

persons.


September 2015

Page 43

Activity Reference



Tai Chi Taylor et al.

(2012)

684 Mean age

74.5

73% female

>1 falls risk

factor

Timed Up n Go

test

Step test

Once a week for

20 weeks

Adjusted incident rate

ratio (IRR) for falls was

no signifcantly different

between the tai chi

group and low level

exercise group

(IRR=1.05).

Improvement in step

test (p<0.001) but not

TUG (p=0.54)

Multiple instructors

delivered the

intervention, thus

high ecological

validity as it follows

current delivery of

tai chi programs

Tai chi not

compared with

inactive group or

control group.

Potential bias as

participants may

have been aware

that ACC has

funded research

and given positive

responses as

means to ensure

ongoing funding of

the program.

No difference in

falls rates

between the

groups, with falls

reducing similarly

(mean= 58%)

over the 17 month

follow up period.


September 2015

Page 44

Activity Reference



Tai Chi Wolf et al.

(1996)

200 Mean age:

76.2

Community

dwelling

elderly

Strength,

flexibility,

endurance, body

composition

ADL’s

Fear of falling

questionnaire,

CES-D scale

10 simplified

movements for

15 weeks

Grip strength declined

in all groups, and

lower extremity ROM

showed limited but

statistically significant

changes.

Fear of falling

responses reduced

post intervention

(p=0.046).

Among tai chi

participants, after four

month follow up, risk of

multiple falls reduced

by 47.5%.

Large number and

variety of tests

Considered

biomedical,

functional and

psychosocial

wellbeing

Can only be

generalised to

community dwelling

elderly with similar

level of mobility and

fitness

Uneven ratio of

males and females

Moderate tai chi

intervention can

impact favourably

on defined

biomedical and

psychosocial

indices of frailty

as well as upon

occurrence of

falls.


September 2015

Page 45

Activity Reference



Tai Chi Voukelatos,

A., et al,

2007

702 Community

dwelling older

people

Confidence

questionnaire

Strength,

balance and

flexibility

Involvement in

the program

80% of the participants

did the Tai Chi for

Arthritis program

Tai Chi for Arthritis

significantly reduced

the number of falls.

Tai Chi for Arthritis

significantly reduced

the risk of multiple falls

by approximately 70%.

Largest fall

prevention study in

the world involved

16 week trial

Used existing

community facilities

Study population

was a fairly robust

group with a mean

age of 69 and most

participants rated

their health as

good, very good or

excellent. This

limits the results to

the study to young

groups of relatively

healthy older

people

Participation in

weekly

community-based

tai chi classes can

reduce falls in

relatively healthy,

community-

dwelling older

people.

The study

suggests that Tai

Chi for Arthritis is

an effective and

sustainable public

health

intervention for

falls prevention

for older people

living in the

community


September 2015

Page 46

Activity Reference



Tai Chi Rhayun, S.,

Eun-ok, L.,

Lam, P.,

Sangcheol,

B., 2003

72 Older women

with

osteoarthritis

Homogeneity

test

Physical

symptoms and

fitness

Body mass

index

Cardiovascular

functioning

Perceived

difficulties in

physical

functioning

The experimental

group perceived

significantly less pain

(t = –2.19, p = 0.034)

and stiffness (t = –

2.13, p = 0.039) in

their joints, and

reported fewer

perceived difficulties in

physical functioning (t

= –2.81, p = 0.008),

In the physical fitness

test, there were

significant

improvements in

balance (t = 3.34, p =

0.002) and abdominal

muscle strength (t =

2.74, p = 0.009) for the

tai chi exercise group.

No significant group

differences in

demographic data

and pre-set

measure

Targeted at women

with osteoarthritis

41% drop out rate

Older women with

OA were able to

safely perform the

12 forms of Sun-

style tai chi

exercise for 12

weeks, and this

was effective in

improving their

arthritic

symptoms,

balance, and

physical

functioning.


September 2015

Page 47

Activity Reference



Tennis Marks (2006) NA Ovid

databases

1966-2005

NA Improved dynamic

balance, cognitive

alertness, joint

proprioception.

Risk of injury

comparatively lower

than other sports.

This review

elucidates the

impact that lifetime

tennis participation

has had on various

health indices.

Based upon the

pitfalls of the

historical tennis

research, this study

provides

recommendations

for designing well

controlled future

research studies

investigating

lifelong tennis

benefits.

Lack of non-

confounded

longitudinal

experimental

research, isolating

tennis as factor for

improved

physiological

outcomes.

Safe to

recommend

tennis to older

adults in an

attempt to

improve balance

and reduce their

risk of falls


September 2015

Page 48

Activity Reference



Walking Asikainen et

al. (2006)

128 48-63

Women

2-10 years

after onset of

menopause

One-leg

standing test

1-2 bouts of

daily brisk

walking for 15

weeks

Continuous and

fractionated

groups

No significant effect on

balance.

Two daily walking

sessions caused fewer

lower extremity

problems than

continuous walking.

Sample size

sufficient for

statistical

comparison.

Exercise dose

controlled with

supervision, HR

monitors, exercise

diaries and

pedometers.

50% of participants

reached a

maximum score in

the baseline

balance testing

therefore

decreased the

possibility to detect

a real training

effect.

Selected balance

test was not

demanding enough

for this population.

Fractionating

walking into two

daily sessions is

more feasible

than continuous

walking


September 2015

Page 49

Activity Reference



Walking Clary et al.

(2006)

44 50-75

Women

Modified Clinical

Test for Sensory

Interaction on

balance,

unilateral stance

with eyes open

or eyes closed,

tandem walk

and step quick

turn tests

Walking 1 hour a

day 3 days a

week for 13

weeks

Sway velocity on firm

and foam surfaces

with eyes closed was

maintained or

decreased for walking

group (p<0.05).

Signifincant

improvements in

speed during tandem

walk test (p<0.01) and

turn time (p<0.01) and

sway (p<0.05) during

step quick turn test.

Balance was

measured by four

different methods

Supervised training

groups following a

predetermined

timeframe

Comparatively

younger age group

means good

postural stability

and balance prior to

training

Gender imbalance

Difficult to compare

MCTSI to results

from Berg Balance

Scale and

functional field tests

Walking program

results in better

improvements in

postural stability

or static balance

when compared

to the Ballates

and step aerobics

programs.


September 2015

Page 50

Activity Reference



Walking Sherrington

et al. (2008)

9,6

03

Varied

between the

studies

Varied between

the studies but

centred on

measuring

strength,

balance and

endurance

Pooled estimate of the

effect of exercise

reduced rate of falling

by 17%.

Greatest relative

effects of exercise on

fall rates (RR = 0.58,

85% CI) seen in

programs that included

higher total dose of

exercise (>50 hours

over the trial period),

challenging balance

exercises and did not

include a walking

program.

Extensive review

Strong exclusion

criteria

Findings consistent

with the little that is

known about

optimal exercise

protocols from

analyses at the

level of individual

participants

Meta regression

trial level

characteristics

warrant caution.

Findings subject to

confounding

variables

Possibility that

coding of program

content does not

reflect real nature

of program

Exercise can

prevent falls in

older people.

However, the

exclusion of

walking program

shows a greater

relative effect on

falls reduction.


September 2015

Page 51

Activity Reference



Yoga Brown et al.

(2007)

22 69-90 Berg Balance

Scale

One Leg

Standing Test

Activity-specific

Balance

Confidence

Scale

13 Hatha Yoga

poses 45

mins/session for

3 months

63.6% of participants

improved BBS scores

(p<0.0001)

68.2% improved OLST

scores (p=0.002)

59.1% improved ABC

scores (p=0.0065)

No significant

differences based on

age, gender or

attendance

Pilot study Short intervention

Small sample size

Lack of follow up

New preliminary

evidence to

suggest that

yoga-based

program may be

effective in

reducing risk of

falls and fall-

related injuries.


September 2015

Page 52

Activity Reference



Yoga Schmid et al.

(2010)

14 >65

Endorsed fear

of falling

Illinois FoF

measure

Berg Balance

Scale

Biweekly yoga

sessions for 12

weeks

FOF decreased by 6%

Static balance

increased by 4%

(p=0.045)

Single armed pilot

study

Limited

ability/power to find

relationships

between variables

and statistically

significant

differences

Participants had

relatively

unchallenged

balance and were

not at great risk of

falling pre

intervention

Yoga is promising

intervention to

manage fear of

falling and

improve balance,

thereby reducing

risk of falls in

older adults.

Yoga Zettergen et

al. (2011)

16 79-88 Berg Balance

Scale

Fast gait speed

Biweekly, 80 min

yoga sessions

for 8 weeks

Paired t-tests revealed

improvements in BBS

scores (t=4.51,

p<0.0003) and fast gait

speed (t=2.69,

P<0.031) of yoga

participants only.

Participants in yoga

group reported feeling

steadier and less

fearful of falling.

Yoga class

designed

specifically for

community-dwelling

older adults

Small sample size

Short intervention

period

Lack of follow up

Yoga can serve

as an effective

intervention to

improve balance

in healthy older

adults.


September 2015

Page 53

Activity Reference



Yoga DiBenedetto

et al. (2005)

19 62-83 Gait speed

Hip extension

ROM

90 min yoga

program, 2

times/week for 8

weeks

Improved hip

extension ROM,

improved stride length

at comfortable walking

speed and non-

significant increase in

self-selected gait

speed.

Pre and post

assessments were

performed in a gait

laboratory

Did not directly

measure falls or

risk of falling

Small sample

size/sample of

convenience

Short intervention

Yoga has positive

effects on gait

speed and hip

extension, both of

which reduce risk

of falling.

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Personal Choice Report - Stay On Your Feet®