Falls and Exercise

Original Editor - Jess Bell

Top Contributors - Jess Bell, Kim Jackson, Lucinda hampton, Ewa Jaraczewska, Vidya Acharya, Admin, Uchechukwu Chukwuemeka, Tarina van der Stockt, Stacy Schiurring and Alexandra Stead

Introduction

Around a third of all people aged over 65 years fall each year. This number increases to 50% of those aged 80 years or over. Risk factors for falls are varied, but they include: a history of falls, weakness, poor balance, visual impairment, polypharmacy, environmental hazards and certain medical conditions, such as arthritis, depression, diabetes and urinary incontinence.

This brief video demonstrates effective fall-prevention exercises.

Ageing and Inactivity

Ageing is associated with a reduction of the functional and physiological capacity of the musculoskeletal and central nervous systems, which significantly affects motor performance. Evidence shows that these age-related declines increase the incidence of falls and re-falls among older people. One-third of older adults above 65 years fall at least once a year, and fall rates increase with age. Falls in older adults occur mainly during dynamic daily tasks.

However, falls are not a normal part of ageing. Ageing is not considered a cause of disability until a person is over 94 years old. However, problems can arise earlier for the following reasons:

1. Disease – 60% of annual deaths under age 75 is preventable through public health interventions targeting an improved diet, exercising more and adopting healthy lifestyle behaviours. These preventable causes include cardiovascular disease, stroke, type 2 diabetes, dementia and depression.
2. Loss of fitness and de-conditioning
3. Negative beliefs about growing older

Inactivity is defined as 30 minutes or less of moderate to vigorous activity per week.

Inactivity typically increases with age. Among adults aged 75-84, 47% are inactive. This number increases to 70% in those aged over 85. This drop in activity contributes to the huge number of falls in this age group.

Why Exercise?

Falls are a common reason for admission to hospital in older adults. However, the most harm occurs when a frail older adult falls. This is because “weak fallers” tend to get stuck on the floor. They also require more care during a hospital stay, which adversely affects quality of life.

The problems associated with falls resulting in the prolonged period of lying on the floor include:

• Hypothermia
• Confusion
• Tissue viability issues
• Pressure injuries
• Dehydration
• Hospital stay

Inactive older adults also have greater muscle atrophy. Muscle tissue usually provides padding, protects joints and preserves bone density. Thus, weak fallers tend to fracture bones more easily. A cross-sectional study suggested that older inpatients had approximately 1.7 times the intramuscular quadriceps muscle adipose tissue of healthy older individuals. Also, the study observed increased intramuscular adipose tissue in older inpatients who were unable to walk independently compared with those who could walk freely.

Exercise can help to address these issues. It helps to preserve and build muscle, thus reducing the risk of falling. According to Ahmadpoor et al., strength training significantly enhances neurophysiological adaptations in older adults, resulting in improved motor control, balance, coordination, and movement accuracy, thereby boosting functional performance. A systematic review of randomised controlled trials suggested that a low dose of creatine monohydrate, along with resistance exercises, may improve upper and lower extremities strength in healthy older adults. A randomised controlled trial (RCT) found a telephone-based falls prevention program with a person-centred approach to be useful at reducing the rate of falls and fractures compared with usual care. Research study by Pereira et al. found significant improvement in postural balance, gait speed of the institutionalised older adults with treadmill training, which was carried out two times per week for 10 weeks.

Physical Activity vs Exercise

Physical activity refers to any activity that increases heart rate, breathing rate and energy demands.

Exercise is a more targeted activity designed to increase fitness. It is a structured form of physical activity designed to improve fitness and well-being.

A patient must understand the distinction between physical activity and exercise. We need them to increase their overall physical activity, but exercise is a targeted intervention to reduce the risk of falls. An older adult needs to do both.

Clinical Applications of the Research

• Exercise prescription should be individualised to each patient, and be based on the intended outcome (e.g., primary prevention, improvement in fitness or functional status or disease treatment).
• Multicomponent programmes, which include balance and strength exercises, are more effective in fall prevention than single-component programmes.
• Holistic mind-motor exercises, including multitasking, may be more effective in fall prevention than exercises focusing on a single physical function.
• To maximise its benefits in reducing falls, exercise must be ongoing, progressively challenging, and administered at a sufficient dose.
• A patient's fear of falling is a critical, but often overlooked, component in fall prevention exercise. Rehabilitation professionals should take a patient's fear of falling into account when prescribing fall-prevention exercises.

The Guideline

Active Lives Adult Survey - Chief Medical Officers' (CMO) Guidelines

The CMO guidelines set out the following minimum threshold for well-being for adults and older adults:

• 150 minutes of moderate exercise per week
• OR 75 minutes of vigorous exercise
• 2 strength sessions per week
• 2 balance sessions per week
• Reduce sedentary behaviour

These guidelines should be considered a target, as many older adults do far less. Our aim as physiotherapists is to encourage older adults to increase their activity levels to the levels outlined above gradually.

American College of Sports Medicine Position Stand on Resistance Training

In 2026 position statement published by the American College of Sports Medicine (ACSM), the authors propose that individualising programs to increase resistance training (RT) participation and adherence is more important for most adults than rigidly conforming to specific resistance training prescription criteria outlined in previous guidelines. They stated that “minimal doses” of RT can bring substantial gains. In addition, RT is crucial for health and is a core component of physical conditioning. In summary, the ACSM recommends that healthy adults perform high-effort resistance training at least twice weekly, engaging all major muscle groups.

NICE Guidelines

The NICE guidelines recommend that strength and balance training should be included in a falls prevention programme. They should be individually prescribed and monitored by a trained professional. This is because exercise is dose-dependent and needs to be set at a suitable level for it to be effective.

Falls and Fracture Consensus Statement

The Falls and Fracture Consensus Statement recommends that most community-dwelling older adults with a low to moderate risk of falls should participate in an exercise programme that includes strength and balance training.

To be effective, this programme needs to be at least 50 hours, with two or more sessions per week.  Group programmes can be supplemented with home exercise programmes.

When creating a programme, it is important to include challenging balance exercises to achieve strength and balance adaptations.

While walking is beneficial in general, it should not be included in programmes for older adults at high risk of falling, as it may result in further falls.

At the end of the 50-hour programme, the patient should be referred on for maintenance classes that suit their needs and abilities,

Cochrane Review

A Cochrane Review, "Exercise for preventing falls in older people living in the community" found that exercise programmes:

• reduce fall rate (by 23%)
• reduce the number of people experiencing more than one fall (by around 15%)
• and may reduce the risk of fractures (by 27%)

An exercise programme must consist mainly of balance and functional exercises. This review could not determine how effective resistance exercise is in isolation, and also notes that walking is not an effective strategy to reduce fall risk.

Physical Activity – A Population Strategy

How can physiotherapists promote physical activity more broadly?

• Provide a variety of options for older adults
• Encourage active travelling. It is also necessary to consider practical, environmental issues like the availability of public toilets and the quality of pavements, and easy-to-use transport systems
• Promote the benefits of physical activity on social media
• Encourage active workplaces – for example, encourage the use of stairs, or cycle to work schemes. This is important as more adults of working age are showing signs of frailty/pre-frailty. If we can encourage activity in working age adults, they may continue these positive health behaviours into their retirement

Key findings of a 2018 review were

• Physical exercise reduces the follow-up risk of falling.
• Exercise interventions for fall prevention may include stability-challenging conditions and perturbations.
• Specification of such exercises (alongside intensity) and understanding of their physiological underlying effect is needed to ensure and improve effective retention of fall-related exercise benefits in the post-intervention follow-up.

Summary

1. Exercise and physical activity are complementary
2. Variety and patient choice are key
3. We need to maximise independence – if an older adult has greater strength, better balance and endurance, they will be more independent, and their risk of falls will reduce
4. The evidence is that physical exercise interventions have the potential to reduce fall rates and risk in healthy older adults significantly. Posture-challenging exercises in particular should be considered when designing fall prevention interventions.

As health professionals, we need to:

• Promote exercise and activity at every contact
• Be certain when we are promoting exercise – it is a very effective intervention, so we need to highlight this
• Be careful with the language we use. For example, phrases like “young at heart”, “take it easy”, or “don’t take the stairs” can reinforce the belief that exercise is harmful and only for younger people
• Collaborate and share learning, facilities, staff and resources

For more information on the problem of falls in hospitals and potential ways to address this, check out this video from Chris Tuckett: