Exercise as it relates to Disease/Resistance and agility training to reduce falls risk in women aged 75 to 85 with low bone mass

A critique of: Resistance and Agility Training Reduce Fall Risk in Women Aged 75 to 85 with Low Bone Mass: A 6‐Month Randomized, Controlled Trial. Liu‐Ambrose T, Khan K, Eng J, Janssen P, Lord S, Mckay H.Liu‐Ambrose T, Khan KM, Eng JJ, Janssen PA, Lord SR, Mckay HA. Resistance and agility training reduce fall risk in women aged 75 to 85 with low bone mass: A 6‐month randomized, controlled trial. Journal of the American Geriatrics Society. 2004 May;52(5):657-65. What is the background to this research? An increase in falls risk is a common occurrence in older populations and is a significant contributor to morbidity and disability.Al-Aama T. Falls in the elderly: spectrum and prevention. Canadian Family Physician. 2011 Jul 1;57(7):771-6. The risk of falling is exacerbated by risk factors including: muscular weakness, reduced balance, longer reaction times, impaired vision or abnormal gate.Berg RL, Cassells JS. Falls in older persons: risk factors and prevention. InThe second fifty years: Promoting health and preventing disability 1992. National Academies Press (US). This study investigates the link between resistance and agility training and falls risk in women aged 75 to 85 with low bone mass. Previous research has been conducted observing the relationship between general exercise programmes and falls risk.Carter ND, Khan KM, McKay HA, Petit MA, Waterman C, Heinonen A, Janssen PA, Donaldson MG, Mallinson A, Riddell L, Kruse K. Community-based exercise program reduces risk factors for falls in 65-to 75-year-old women with osteoporosis: randomized controlled trial. Cmaj. 2002 Oct 29;167(9):997-1004. This study expands upon previous research by focusing on the effects resistance and agility training have on fall risk. Research in this population is essential in the identification of risk factors and fall prevention strategies. Through the prevention of falls in older populations, quality of life can be significantly improved.Bjerk M, Brovold T, Skelton DA, Bergland A. A falls prevention programme to improve quality of life, physical function and falls efficacy in older people receiving home help services: study protocol for a randomised controlled trial. BMC health services research. 2017 Dec 1;17(1):559. A reduction in falls in older populations also reduces the economic burden related to medical care required following falls.Heinrich S, Rapp K, Rissmann U, Becker C, König HH. Cost of falls in old age: a systematic review. Osteoporosis international. 2010 Jun 1;21(6):891-902. Where is the research from? This study was conducted in Canada and received funding from the Vancouver Foundation (BCMSF), the Canadian Institutes of Health Research, and the Michael Smith Foundation for Health Research. All authors contributing to this research declared no conflicts in interest. What kind of research was this? The study completed was a single blind randomised control trial. Randomised control trials are considered to be one of the most reliable study designs and are an effective method of establishing whether or not a correlative relationship exists between two variables.Bhide A, Shah PS, Acharya G. A simplified guide to randomized controlled trials. Acta obstetricia et gynecologica Scandinavica. 2018 Apr;97(4):380-7. The randomisation of subjects and the implementation of single blinding ensures a reduction in selection bias and reduces the possibility of results being impacted, either intentionally or unintentionally.Kabisch M, Ruckes C, Seibert-Grafe M, Blettner M. Randomized controlled trials: part 17 of a series on evaluation of scientific publications. Deutsches Ärzteblatt International. 2011 Sep;108(39):663. What did the research involve? The primary outcome measured in this study was to study the effect that various exercise interventions had on the fall risk of women aged 75 to 85 with low bone mass. Fall risk scores were calculated using the Physical Profile Assessment (PPA), which assessed strength, postural sway, proprioception, reaction time and vision. Subjects were allocated into one of three intervention groups. The first intervention group was a resistance-training intervention. The resistance training targeted the trunk and extremities and was designed to be high-intensity and progressive. A second intervention group underwent an agility-training programme which predominantly targeted coordination, static and dynamic balance, and reaction times. The final group took part in a stretching programme and acted as an active control group. This programme focused on stretching, deep breathing, relaxation and posture. All groups completed two 50-minute sessions per week. The participants were assessed at baseline, at 13 weeks, and at the end of the 25-week intervention. What were the basic results? thumb|upright=2|Figure 1. Fall risk scores at baseline, midpoint and final assessment compared by intervention Over the 25-week training period, the resistance training was the only intervention that led to a significant reduction in fall risk scores. The resistance intervention also displayed improvements in quadriceps strength, postural sway, reaction time, proprioception and edge contrast. In the agility intervention, the most significant improvements were made in postural sway and reaction times; however, improvements were less than those made in the resistance group. In their analysis, Liu-Ambrose et al. state that the fall risk scores of the resistance intervention group were reduced by 57.3%, the agility intervention group scores were reduced by 47.5% and the scores of the stretching group were reduced by 20.2%. Based on the data gathered in this research, the actual reduction in falls risk scores was 54.5% for the resistance group, 29.2% in the agility group and 21.1% in the stretching group. Liu-Ambrose et al. also indicated that the agility intervention underwent a reduction in fall risk score between the midpoint and final assessments; however, based on the data provided, this is inaccurate and likely due to either an error in data collection or in the analysis. This error led to an over-emphasis of positive results in the agility intervention group. + Table 1: Fall risk scores at baseline, midpoint and final assessments Baseline (Mean±SD) 13 Weeks (Mean±SD) 25 Weeks (Mean±SD) Resistance 2.2±0.7 1.4±1.0 1.0±1.0 Agility 2.4±0.9 1.5±1.0 1.7±0.9 Stretching 1.9±0.8 1.5±1.0 1.5±1.2 What conclusions can we take from this research? While results from the stretching and agility interventions were either insignificant or unclear, this research outlines a significant association between resistance training and a reduction in fall risk in older women with low bone mass. From the data presented, a conclusion can be drawn that resistance training in older women with low bone mass can lead to a reduction in fall risk. This conclusion, made based on the findings of this research, is also supported by the results published by LaStayo et al.LaStayo PC, Ewy GA, Pierotti DD, Johns RK, Lindstedt S. The positive effects of negative work: increased muscle strength and decreased fall risk in a frail elderly population. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2003 May 1;58(5):M419-24. No conclusions can be drawn in support of the implementation of agility training programmes due to the inconsistencies found in this research. Practical advice Based on the findings of this research, implementing resistance-training programmes for older adults with low bone mass, identified as high fall risk, may be beneficial. The implementation of resistance training programmes in at-risk individuals is likely to reduce falls risk, increase bone mass and improve quality of life. Resistance training programmes implemented should be carefully monitored to ensure adaptations and prevent injury. Implementation of a supervised intervention is also likely to increase programme compliance and lead to greater adaptations compared to self-monitored, home-based programmes.Fennell C, Peroutky K, Glickman EL. Effects of supervised training compared to unsupervised training on physical activity, muscular endurance, and cardiovascular parameters. MOJ Orthop. Rheumatol. 2016;5(5). Prior to beginning the intervention, subjects should be assessed using the pre-exercise screening tool and exercise risk factors should be identified and assessed. The programmes implemented should consist of two sessions per week, as per resistance exercise recommendations, and should be progressive in nature and increase load over time to ensure continued improvements in muscle strength.Fragala MS, Cadore EL, Dorgo S, Izquierdo M, Kraemer WJ, Peterson MD, Ryan ED. Resistance training for older adults: position statement from the national strength and conditioning association. The Journal of Strength & Conditioning Research. 2019 Aug 1;33(8). Further information/resources Stay On Your Feet - professional resources: https://www.health.qld.gov.au/stayonyourfeet/for-professionals/resources-prof Fall Risk Assessment: https://www.hopkinsmedicine.org/institute_nursing/models_tools/fall_risk.html Falls Fact Sheet: https://www.healthdirect.gov.au/falls Growing Stronger - CDC Training Programme: https://www.cdc.gov/physicalactivity/downloads/growing_stronger.pdf References