Dozens of statistics support the myth that falls are a normal part of aging. Each year, one third of adults over age 65 and half of those over age 85 fall,¹ resulting in approximately 1.6 million emergency department visits.² Falls are the sixth leading cause of death in older adults.² For those who survive, about 10% require hospitalization for serious injuries, including fractures, subdural hematomas, and soft tissue injuries.² Even two months after a fall, 40% of seniors seen in the ED still complained of pain or activity restriction.3 People who fall experience a greater functional decline in activities of daily living (ADLs) and in physical and social activities than people who do not fall.³ Approximately 40% of nursing home admissions are related to a fall.⁴ Fortunately, falls are preventable in most cases, and fall risk can be reduced regardless of a person’s age. Exercise has been shown to play an important role and have a positive impact on fall prevention.

Fighting Falls with Exercise

To remain healthy, people of all ages require regular exercise,^5-9 and in no other age group is exercise more important than with those over 65. As the body continues to age, physiological deterioration becomes more apparent. Inactivity is a major contributor to this decline.⁶ As functional status declines, people become more at risk of becoming institutionalized. They exist just above a critical functional threshold below which they are no longer safely able to remain independently living in their homes Many are only one illness or injury away from permanently losing their independence.¹⁰ Thankfully, it is never too late to begin an exercise program to enhance strength and balance and move farther from this threshold. One study reports that people who began to exercise in their 60s had positive responses similar to those who had been active all their lives. These people had better postural stability than their sedentary counterparts who had been active in their 30s and 40s.⁷ While exercise is essential to all older adults, those who are living at or near the critical functional threshold (i.e. just barely managing at home) have demonstrated the most profound benefits as a small degree of strengthening translates into a disproportionate improvement in function.¹

Dozens of studies describe the benefits of exercise.^5,11-15 Many include a multifaceted approach, which address both extrinsic and intrinsic risk factors. One investigation reported that exercise decreased fall risk in those who had intrinsic risk factors for falls, such as weakness, poor balance, or impaired functional mobility.¹³ Another found improved Berg balance scores in subjects who completed three months of strengthening, balance, coordination, and endurance exercises along with taking protein supplements, vitamin D, and calcium. The subjects in the intervention group had 75% fewer falls after a year, while the control group had a 20% increase in falls.¹⁴ A third study described a community program focusing on strengthening, aerobic activity, and balance where the intervention group had 40% fewer falls after one year compared to the controls.⁵ Finally, an additional study demonstrated significant gains in muscle strength and improved timed “Up & Go” scores.¹⁶ When compared to other fall prevention interventions, such as vision checks and home environmental modifications, exercise was the only intervention that, by itself, had a positive impact on fall prevention,¹⁷ reducing fall risk by as much as 35% to 45%.⁹

Seniors who exercise not only remain stronger and have fewer falls than their sedentary peers, but they also benefit from stronger bones and a lower risk for a fracture if they do fall. Even seniors who have already experienced a fall resulting in a serious injury can still safely participate in an intense exercise program.¹⁶ Exercise can also help elders manage chronic conditions such as diabetes and hypertension, and it may delay potential disability from these conditions.¹

Elders may gain a psychological benefit from exercise.² One study has shown that scores on the 15-item Geriatric Depression Scale improved with exercise.¹⁸ Individuals who were previously isolated due to their fear of falling may become more social as well as perform at higher functional levels, due to increased confidence about their abilities.⁸

What Exercise is Best?

The most important areas to target with exercise are strength, balance, coordination, and reaction time.^3,7,19 For optimal results, progressive resistive exercise with weights should be included to maintain or improve bone density and decrease the risk of a fracture.⁷ Increased muscle mass also cushions bones during a fall.⁶ Following are a compilation of expert recommendations for strength, balance, aerobic, and flexibility training.

Strength training is essential for fall prevention^5-11,17 and can replace some of the Type-II muscles fibers that are lost due to aging and inactivity.⁶ In older adults, lower extremity strength is lost more quickly than upper extremity strength. Important muscles to target are the hip extensors, knee extensors, hip abductors, and ankle plantar flexors and dorsiflexors.²⁰ These muscles are essential during basic functional tasks, such as sit-to-stand and gait, especially since people who have fallen have greater difficulties with these tasks than those who have not fallen. The ankle muscles respond as part of the first reflex to recover balance when it is lost.²⁰ For example, if a person’s center of gravity deviates too far posteriorly, the anterior tibialis muscles contract forcefully to return the center of gravity over the base of support.

Precautions and contraindications need to be considered with a strength-training program. For patients with cardiac risk factors, a weightlifting stress test similar to a traditional treadmill stress test is recommended. In this test, the patient lifts three sets of eight repetitions at 80% of one repetition maximum (1RM), while ECG and blood pressure are monitored.⁶ Patients with osteoporosis need to avoid activities with trunk flexion because this places an unsafe amount of force on the fragile anterior vertebrae and can lead to compression fractures.⁸ Those with rheumatoid arthritis or osteoarthritis should exercise in a pain-free range.⁹ Isometric exercises with a gradually increasing hold time are helpful to build strength without increasing pain.⁸

When instructing patients in a strength-training program, the recommended number of repetitions varies from 10 to 15, but the intensity should be between 60% and 100% of 1 RM, the maximum amount of weight that can be lifted one time. If one lifts a weight 20 times, it becomes more endurance rather than a strengthening activity.⁶ Two sets of 10 repetitions with a one- to two-minute rest between sets are more effective than one set.¹⁷ One should inhale before the lift, spend two to three seconds on the concentric contraction while exhaling, and then four to six seconds for the eccentric or lengthening contraction.²⁰ Remind exercise participants to ‘Exhale while you exert,’ as holding their breath may cause a valsalva maneuver in which intrathoracic pressure increases, compressing the vena cavae and reducing blood flow to the heart. Strengthening exercises should be performed two to three times per week on nonconsecutive days.⁹ A gradual increase in resistance is necessary to make gains^9,20 with experts recommending increasing resistance every two to three weeks.⁶ Though most studies provided strength training three times per week, a 10% to 15% increase in strength per week should be observed even with strength training only twice per week.⁶ Improvements in strength do not always equal improvements in fall risk or function.¹⁷

Strike a Balance

Strength is one part of the fall prevention puzzle, but balance training is another critical component. Balance exercises must target both awareness of an impending loss of balance and the ability to correct for a balance loss before it becomes a fall.⁷ The individual must be able to adequately weight shift for functional tasks and exhibit anticipatory postural control to stabilize the trunk prior to moving the limbs.⁸

Interventions need to address ankle range of motion, proprioception, and sensation as well as increase strength, coordination, and reaction time.⁷ Since most falls are due to tripping or slipping, the righting reactions of the legs, more than the trunk, are critical. The anterior legs must especially be strengthened.²¹ When balance is lost, seniors must be able to recover by using their legs with an ankle or hip strategy, not by grabbing for nearby stationary objects.²¹ Altering sensory conditions may also help improve the sensory systems that control balance. For example, standing with eyes closed removes visual input and forces the brain to rely more on sensory input from the feet and ankles. Standing on a foam cushion hinders sensory input from the feet and trains the body to rely more on the vestibular and visual systems.⁸ Since working on these static standing balance tasks does not translate into dynamic balance gains during gait, it is important to also challenge the patient’s balance during gait.²² This can be done by altering the environment to include uneven surfaces, inclines and stairs, and decreasing lighting.⁸ Some successful dynamic balance interventions include reaching while stepping forward and sideways, stepping over and around obstacles, walking backwards, single-limb stance, tandem walking, turns while walking, and picking up objects off the floor.^13,23 Balance retraining strengthens postural control, but patients may be at a slightly higher risk for falling as they begin a new task.²³ Exercises should initially be completed with supervision from the PT; then patients can perform them while standing beside a wall, counter, or sturdy piece of furniture for support if needed. Patients should not perform dynamic balance activities, such as tandem walking or negotiating obstacles, without the PT.

In discussing balance, consider that tai chi exercises alone have been found to delay the onset of a first fall or multiple falls by 47.5%.^7,24 Tai chi consists of slow, rhythmic movements emphasizing trunk rotation, controlled weight shift, coordination, and a gradual narrowing of the base of support.²⁵ These exercises enhance strength, flexibility, balance, blood pressure, and cardiorespiratory function.²⁵ This type of movement strengthens vestibular and proprioceptive feedback for a faster perception of a balance loss and reaction time along with addressing anticipatory postural control.^24,8 Tai chi classes should not replace a thorough balance assessment by a PT, but they can be a successful maintenance plan for a higher functioning patient who has completed a PT program. Patients just beginning to perform tai chi should only do so under the guidance of a PT or master tai chi instructor. As patients advance in their movement patterns, they may be able to perform the simpler forms independently. It typically takes up to three months before participants can fully complete a movement pattern without the use of an assistive device.²⁵

Cardiopulmonary and Flexibility Training

Cardiopulmonary training is an essential part of a senior exercise program. Though aerobic activity alone does not decrease fall risk, it helps to improve overall activity tolerance, blood pressure, and cholesterol levels, reducing the risk for heart disease and its resulting functional limitations.⁸ The American College of Sports Medicine and American Heart Association advise aerobic activity, such as walking, swimming, or stationary bicycle, at least five times per week of moderate intensity (5 to 6 on a 10 point scale) or three times per week of vigorous activity (7 to 8 out of 10). This correlates to 55% to 90% of the maximal heart rate.²⁶ The duration of moderate exercise should be at least 30 minutes, though this can be divided into 10-minute increments if necessary. Vigorous activity should be continuous for at least 20 minutes.⁹

Flexibility is the other essential component for preventing falls. Without adequate flexibility, a body cannot respond appropriately to a balance loss, especially in the ankles. Flexibility should be included in the exercise routine at least twice per week with stretches being held for 10 to 30 seconds without bouncing and be repeated three to four times.⁹

Focus on Institutionalized Seniors

Fall prevention in skilled nursing facilities and other institutions is especially critical as nursing home residents experience many more falls, fractures, and fracture-related deaths than community dwellers.^2,11 Range of motion exercise programs in nursing homes are often not challenging enough to produce a change in a resident’s balance or fall risk.¹⁰ Seated training is not helpful in increasing balance; to be effective, one has to forego postural support. Strength training alone is also ineffective. The resident requires some combination of balance and strength training.¹⁰ Additionally, nursing staff may contribute to a resident’s loss of independence by providing too much assistance. Residents may get too accustomed to accepting help and lose their motivation to be more independent.¹⁰ PTs should clearly document the level of assistance required for each patient so that nursing assistants can reinforce therapeutic interventions and goals.

A 2008 questionnaire assessed exercise in 26 Massachusetts nursing homes.²⁷ The investigation compared the current recommendations in the literature for exercise in nursing home residents to what was actually being offered. Questions addressed exercise limitations either due to the resident or staffing issues. One question asked, “What are some reasons why residents [staff] might not be compliant with an ambulation program?” Nursing staff feared residents would fall during more challenging exercises. They felt there was inadequate supervision to guard residents while they ambulated independently or performed other exercise. There were concerns that resistance training might trigger a cardiac event. Time constraints made implementation difficult, especially if a resident needed more encouragement to participate or if staffing was limited on a particular day. The severe disabilities of many residents and complexities of agitation, confusion, anxiety, pain, and poor activity tolerance hindered exercise. Finally, the residents’ attitudes limited exercise in some cases. Some residents felt they were “too old” and “did not need exercise.” Others were too busy with other recreation programs to fit exercise into their routine, consistent with another exercise study carried out in a long-term care facility.¹¹ Adherence to the intervention exercise program was poor as the participants frequently chose to attend other recreational programs.

Additional Concerns for Institutionalized Seniors

Some of the complexity of fall prevention is related to the heterogeneous nature of the elderly population. The most active seniors may engage in more strenuous activities that may place them at risk for falls, such as sports or heavy yard work. Less active seniors no longer participate with these risky activities; hence, their risk for falling may be lower. However, at some point, their inactivity begins to work against them as they transition toward frailty. The characteristics of frailty include weakness, exhaustion, unintentional weight loss, slowness, and reduced physical activity.¹³ A person is considered frail if he or she presents with three or more of these characteristics. Many nursing home residents would fit this category. Comparison of exercise exists in the literature for those who are frail and those who are prefrail (moving toward frailty) or nonfrail. One study found that functional mobility and dynamic gait training or tai chi actually increased fall risk in a frail intervention group compared to a 61% reduction in fall risk in a prefrail group.¹³ Frail seniors need more intensive, individualized strengthening programs.

Strength training is important, because those who are living just below the critical functional threshold may discover a substantial improvement in function after participating in a resistance-training program. Researchers believe many healthcare workers underestimate the abilities of the frailest elderly to participate with strength training.¹ Weights should be used and adjusted as residents gain strength. Balance exercises are a crucial part of a fall reduction plan for institutionalized elders. However, the reason why exercise programs for fall prevention are often unsuccessful in nursing homes is that the therapist may fail to consult with the interdisciplinary team. Many factors may contribute to falls, so the prevention approach must be multidisciplinary.¹ Physicians or pharmacists should review medications because many may increase fall risk. Nursing staff should monitor for signs of dehydration, poor nutrition, or impending illness, such as pneumonia or a urinary tract infection. A dietician may consult for malnutrition. A psychiatrist should assess for depression, which may limit activity.

The most successful long-term institutionalized exercise programs are uncomplicated and scheduled into daily activities.¹² Exercise programs that include lower body strength and balance training have been shown to reduce fall risk by 10% to 49%.² One team of researchers designed a simple program comprising three sets of 10 to 15 heel raises and 10 minutes of continuous ambulation three times per week for three months. After the intervention, the exercise subjects demonstrated improved ambulation speed, falls risk reduction, and falls efficacy (fear of falling), though these results were not statistically significant due to a small sample size.¹² The primary author suggests that chair push-ups be included in any seated-exercise programs. Residents place their hands on the armrests of their chairs and attempt to lift their buttocks off the seat as if initiating sit-to-stand. This exercise is functional and addresses the ability of the hamstrings to stabilize the lower leg to allow the reverse action of the quadriceps against the resistance of the patient’s body weight. Finally, ankle cuff weights and hand weights should be given to participants as tolerated to change simple ROM exercises to strengthening exercises.

Additional suggestions came from the Massachusetts nursing home questionnaire.²⁷ Though only anecdotal, nursing supervisors reported improved certified nursing assistant (CNA) compliance with ambulation when consistent assignments were instituted. CNAs felt more invested in their residents’ health and function and made an additional effort to ambulate them. Residents were more trusting and felt more comfortable ambulating with their consistent CNAs. Other facilities incorporated ambulation into the daily schedule of all staff, even those outside of rehabilitation and nursing. “Walk to Dine” was the name of one program where ambulatory residents walked to meals. Rehabilitation personnel taught nonclinical staff about guarding techniques for safe ambulation. Residents who participated in a walking program have demonstrated improved ambulation and a reduced number of falls.¹²

Challenges to Exercise Program for Older Adults

One of the greatest challenges of creating exercise programs for older adults is adherence.²⁸ One study found that subjects who were fully adherent to an exercise program had a greater reduction in fall risk than those who were only partially adherent.²⁹ Twelve weeks are often necessary for tangible results to be observed, so an older adult should not give up if immediate gains are not seen.¹³

Education regarding the health and lifestyle benefits of exercise should be initiated by primary care providers.⁵ PTs should ascertain that local physicians are including fall risk as part of patients’ annual screenings. Patients should be told that adherence with an exercise program is as important as taking their prescription medications.

Another challenge for older adults is finding a safe, effective exercise routine. When patients are in inpatient settings, a discussion about a long-term exercise plan should be initiated before discharge. A home exercise program should be designed by inpatient or home PTs. Family members should be instructed in the prescribed exercise program and encouraged to buy ankle cuff weights, hand weights, or elastic tubing. Home physical therapy is only short-term, and there needs to be more outreach to homebound seniors.

Boston University’s Health and Disability Research Institute has designed the award-winning video Strong for Life; created by PTs, it demonstrates safe, effective exercises that can be done in the home to improve strength, balance, and overall health.³⁰ Elastic bands are used as resistance. The video also shows ways to advance the exercise program as the viewer grows stronger.

For older adults who are no longer homebound, many malls open early to allow older adults to walk in a safe, level, climate-controlled area with benches for rest. Before discharge, home PTs should offer information from local senior centers with schedules of exercise classes they offer. Unfortunately, community exercise programs are lacking in some areas. PTs can help to train staff from various agencies to implement effective, safe exercise programs consisting of aerobic, balance, strength, and flexibility components. Public health exercise programs should be simple, low-cost, and easily instituted by trained laypersons.^18,20 Group programs have been proven to be as effective as individualized maintenance programs,5 and participants often enjoy the social benefits of these groups.^12,28

Hosting community exercise programs can also serve as a marketing tool for inpatient facilities or outpatient PT clinics. The Matter of Balance Program, originally developed at Boston University, is an evidence-based program that incorporates balance and resistance exercises, education on environmental hazards and “fall-ty” habits, and behavioral modification to combat the fear of falling.³⁰ The primary goal of the program is to reduce the fear of falling through cognitive restructuring with the secondary aim of improving functional status and socialization. Participants use their own “personal action planners” to formulate plans to remove environmental hazards from their homes, fit more exercise into their daily routine, and change risky behaviors. This program consists of nine two-hour-long classes led by trained instructors.

Limitations to Senior Exercise Research

Occasionally, studies may demonstrate minimal benefit from exercise, though there are often explanations for this. Multiple factors limit studies examining exercise in older adults. Many articles displayed methodological errors, such as absence of blinded evaluators or blinding amongst subjects.¹⁰ Often it is difficult to formulate a large enough sample size to attain significant results. Many seniors are hesitant to begin a new exercise program, or transportation to the exercise location may be inconsistent. Multiple medical conditions make attrition a concern.¹² Subjects may fall and sustain an injury that excludes them from the study, or they may become too ill to participate. Comorbidities may skew the results of a study. Though researchers’ attempt to exclude those with diagnoses that may negatively impact the results, such as severe cardiac disease or progressive neurological  disorders, control for vision, prescription drug use, or environmental hazards is nearly impossible.

In some studies, the control group participated with a wellness education program with information on fall prevention. This education may have lowered the fall risk in the control groups just enough to reduce the significance between the two groups.^20,25 In other studies, a significant difference in fall risk was not found between the intervention and control groups because the intervention group was already at a low fall risk, and there was little room for their risk to become lower than it already was.^3,31

A multicenter randomized control trial may further explore the different responses between nonfrail, prefrail, and frail seniors. Often the results of an exercise program depend upon the previous health and functional status of the subjects. Some programs may not be intense enough for nonfrail individuals and may not facilitate a measureable gain. Other programs are too intense and place the older adult at a higher fall risk.

Falls continue to be a major threat to the health, safety, and independence of those over the age of 65. The number of falls experienced annually is expected to rise as the population ages. Exercise has been proven to be the only intervention that, on its own, can reduce this number of falls.⁹ Exercise programs implemented to reduce falls need to have strength and balance components.^3,7 Both individualized and group exercise programs have been effective in lowering falls.5 For those who are becoming frail, exercise often has a profound effect and can make the difference between an independent and an institutionalized life.¹

Older adults must be educated about the benefits of exercise across healthcare settings. Exercises programs that are successfully established in the inpatient setting must be communicated to home care and outpatient therapists and physicians. Many states are now developing fall prevention coalitions, consisting of medical and social personnel across all settings, which can offer valuable resources to remedy seniors’ fall risk factors. One such organization is the National Council on Aging, which is part of the Falls Free Coalition (www.healthyagingprograms.org) and includes information on how to develop a falls coalition.² The NCOA (www.ncoa.org) has many excellent resources, including legislative updates and free or low-cost programs for seniors. A Tool Kit to Prevent Senior Falls is also available from the National Center for Injury Prevention.²