Ph ysioth era p y Theory a n d Pra ctice ( 1999) 15, 105–120

© 1999 Psycholog y Press

Exercise for falls management:

Rationale for an exercise programme
aimed at reducing postural instability

Dawn A. Skelton and Susie M. Dinan

It is evident in the scientific and health promotion literature that interest in

methods of reducing the risk factors associated with falls, in falls themselves, and
in fall-induced injuries is increasing. However, the scientific evidence supporting
the role exercise has to play in the management of elderly people who fall is
inconsistent and, therefore, confusing. There have been calls for further research
evidence, models of practice, guidelines on prevention, and treatment initiatives.
Strategically, current guidelines are helpful but more detail is needed in order to
assist practitioners to design effective exercise programmes for this vulnerable
group. This paper provides a rationale for a specific, tailored, progressive
programme of exercise. The programme not only incorporates all the basic fitness
components seen in any well-run seniors’ exercise class, but also includes specific
falls management strategies, such as bone loading, gait, dyn amic posture, balance,
reaction and co-ordination training, together with adapted Tai Chi and functional
floor activities to improve coping skills and confidence. This Falls Management
Exercise Programme ( FaME) is being evaluated in a controlled trial, funded by
Research into Ageing and conducted at Imperial College School of Medicine,
London, UK.

INTRODUCTION systematic reviews of randomised, controlled,

intervention trials ( Sowden et al., 1996; Gillespie
To date, there are no national guidelines giving et al., 1997) concluded that exercise reduces the
detailed, specific advice on exercises for falls pre- risk of falling as part of multifactorial intervention.
vention and exercise protocols in old age. Two Since then, however, Campbell et al. ( 1997) have
shown how falls can be reduced by an individual
programme of strength and balance exercises,
Daw n Skelton, Exercise Physiologist, Cellular and
Integrative Biology, Division of Biom edical which they list. Possibly the only detailed, pub-
Sciences, Im perial College School of Medicine at lished account of an exercise intervention
St Mary’s, Norfolk Place, London W2 1PG, UK. programme is given by Koch et al. ( 1994) , who
e.mail: [email protected]
Susie Dinan, Senior Clinical Exercise Practitioner, describe the assessment and intervention protocol
Royal Free Hospital, Pond Street, London they developed for a multifactorial home-based
NW3 2QG, UK. intervention programme ( Tinetti et al., 1994) .
(Reprint requests to DS) Neither of the systematic reviews made recom-
Accepted for publication February 1999 mendations for exercise that were sufficiently
106 PHYSIOTHERAPY THEORY AND PRACTICE

specific to be implemented by practitioners. deficits contributing to a higher risk of falls or

Guidelines commissioned by the Health Promo- fall-induced injuries that can be ameliorated by
tion Division of the Department of Health in the exercise training. It is also necessary to differenti-
UK are valuable for developing multifactorial ate between risk factors for falling and outcomes
interventions for falls prevention but give no spe- or consequences of falling. For example, depres-
cific advice on exercise other than that it should sion is a risk factor for falls, as well as an outcome of
involve muscle strengthening and balance work, falls ( Thapa et al., 1994; Rizzo et al., 1998) . Over
especially Tai Chi ( Feder, Cryer, & Donovan, 400 risk factors have been identified ( see Sowden
1998) . Guidelines have been produced for physio- et al., 1996 and Piotrowski Brown in this issue) .
therapists and occupational therapists working Some of them, such as inappropriately prescribed
with older people who have fallen ( Simpson, Har- drugs, vitamin D deficiency, environmental haz-
rington, & Marsh, 1998; Simpson, Marsh, & Har- ards, and type of footwear worn, cannot be influ-
rington, 1998) . The recommendations include enced directly by exercise. However, most intrinsic
balance training, strengthening the muscles physical risk factors, such as low muscle strength,
around the hip, knee and ankle, increasing flexi- poor balance, and gait deficiencies are amenable
bility ( range of motion) of the trunk and lower to change with exercise. Cwikel and Fried ( 1992)
limb, teaching how to rise from the floor, and the formulated a conceptual model that considers
provision of mobility aides and appliances if neces- both the risk factors for falls and the agents
sary. These guidelines are positive and helpful. involved in falls. They proposed “a complete fall
However, they do not give specific advice about the prevention strategy” comprising primary ( pre-fall
selection and combination of exercises, or about stage) , secondary ( at the time of the fall) , or ter-
intensity, duration, frequency, baseline measures, tiary ( post-fall stage) prevention.
or increments of progression. A welcome forth- Physical fitness is especially important in old
coming document from the Health Education age. Without it, everyday tasks and unforeseen
Authority, however, will provide a framework for demands such as slopes, uneven ground, trips, and
practice in the use of physical activity and the man- even everyday tasks such as getting up from the
agement of fractures and falling ( Health Educa- toilet may place insurmountable demands on the
tion Authority Older People’ s Programme, 1999) . ageing body ( Fentem, Bassey, & Turnbull, 1988,
This paper aims to integrate evidence and prac- Skelton and McLaughlin, 1997) . Although several
tice in order to provide practitioners with a frame- muscle groups in the lower limb may well be
work for selecting specific, tailored, progressive weaker amongst fallers ( Whipple, Wolfson, &
exercises that can be adapted to suit older people Amerman, 1987; Lord, McLean & Strathers,
with a wide range of physical abilities. The frame- 1992) , few studies have examined muscle groups
work is organised around a 4-point plan to other than the quadriceps, ankle dorsiflexors, and
improve balan ce, fu n ction al capacity, bon e an d m u scle plantarflexors. Moreover, the hip flexors and
m ass, and con fiden ce. This programme, in addition ankle invertors and evertors appear to be
to including the basic fitness components seen in neglected. Apart from Whipple et al. ( 1987) no
any carefully constructed seniors’ class, also incor- researcher seems to have measured isokinetic
porates specific falls management activities. These strength, which is probably important in pre-
include sustained three-dimensional Tai Chi- venting falls. Similarly, muscle power ( strength ´
based movement patterns, targeted strengthening speed of contraction) is rarely assessed. Lo wer
and stretching exercises, dynamic postural and limb muscle power, however, is likely to be very
gait training, and functional floor and standing important in correcting a displacement or move-
activities to improve postural skill and confidence. ment error ( Bassey et al., 1992) . To prevent a trip
The programming design utilises a combination an individual must have sufficient lower limb
of supervised and home-based sessions and tele- muscle power to get a stabilising leg ( or enough
phone support. upper body power to get a stabilising arm) out fast
Before designing a falls management exercise enough to prevent the fall or reduce the severity of
programme, it is important to identify the physical the effects of the fall ( see Maki in this issue) . Also,
 PHYSIOTHERAPY THEORY AND PRACTICE 107

muscle power is strongly related to ability to Changes in gait pattern may also be associated
perform everyday tasks ( Skelton, Greig, Davies, & with balance ( Nasher, 1993) . Older people tend to
Young, 1994) . Among elderly women who had step with a wider base, spending increased time in
surgery to repair a hip fracture, muscle power was the double leg support phase of walking and
70% less in the uninjured leg, than their healthy minimising the time spent on one leg. There is,
counterparts ( Levy, Young, Skelton, & Yeo, 1994) . therefore, a decrease in stride length and trunk
In addition to size, number, and type of muscle rotation, with the result that a more unbalanced or
fibres, muscle power at any age is related to the even shuffling gait may develop. When required to
length of the muscle ( Harridge & Young, 1998) . increase walking speed, older people tend to
Adaptive shortening due to immobility also increase their cadence rather than their stride
reduces muscle power. Reduced sensory input length; younger people do the reverse ( Greig et
exacerbates the inefficiency of musculoskeletal al., 1993) . Older people with diseases such as
systems in correcting a displacement or movement peripheral neuropathy, arthritis, and osteoporosis
error and stabilising posture. Age-related changes are likely to adapt their gait even more to relieve
in connective tissue results in further reduction of stress and pain.
flexibility, loss of tensile strength in the ligaments, Fear of falling can also cause older people to
and greater rigidity in the muscles and peripheral limit their movement ( Tinetti, Speechley, &
support structures of the joints of the lower limb. Ginter, 1988) , not just in terms of habitual activity
Poor balance is prevalent amongst fallers but also in their normal body movements ( Murphy
( O’ Brien, Culham, & Pickles, 1997) and many of & Isaacs, 1982) . Reluctance to move can lead to
the risk factors for postural instability are largely poor co-operation with rehabilitative methods
due to inactivity and ageing muscles ( Lord, Clark, Murphy & Isaacs, 1982) and avoidance of a
& Webster, 1991) . Balance is a complex automatic particular activity that led to a fall ( Tideiksaar,
integration of several body systems. With age and 1989) . The trunk becomes more rigid so that
inactivity these unconscious processes may not rotational movement of the pelvis is reduced
integrate as well or as quickly, so in order to which can lead to pain and discomfort that limits
maintain their balance and avoid falling older further movement ( Patla, 1994) . Movement errors
people may have to give a greater proportion of or novel movements are known to facilitate the
their attention to keeping upright with concomi- acquisition of motor skills so conversely, fallers
tant fatiguing effort. The “stops walking when may inadvertently cause a loss of postural skills by
talking” phenomenon reflects this difficulty constraining their own movements ( Nasher,
( Lundin-Olsson, Nyberg, & Gustafson, 1997) . 1993) .
Body sway is commonly regarded as an indica- Other age-related changes that may affect pos-
tor of postural stability. We all sway slightly during tural stability include the reduction of reflex
quiet standing, but in older adults, particularly in speeds and poor co-ordination, and vestibular dys-
women, sway is more evident, especially during function ( often medication related) may mean
single leg standing ( Nasher, 1993) . On a firm sur- there is overlap between the timing of reflexes and
face, Lord, Clark, and Webster ( 1991) found that the voluntary responses to correct the loss of bal-
increased body sway was related to poor tactile sen- ance. In our experience, these negative changes in
sitivity and poor joint position sense. On a compli- response and loss of flexibility and strength in the
ant surface ( which reduced peripheral sensation) , muscles and joints of the lower limb, seem to result
increased body sway was related to poor visual in people relying more on the larger muscles of
acuity, reduced vibration sense, decreased ankle the upper leg and trunk. Balance detection and
dorsiflexion strength, and poor joint position correction is also influenced by reduced sensitivity
sense. When subjects had their eyes closed, sway of skin receptors ( oedema, arthritis, and medica-
was more related to quadriceps and ankle tions) ( Patla, 1994) .
dorsiflexion strength and increased reaction time. Functional difficulties are common amongst
Vestibular impairment was not associated with fallers ( Wolinsky, Johnson, & Fitzgerald, 1992) , for
increased sway. example, their ability to get up off the floor after a
108 PHYSIOTHERAPY THEORY AND PRACTICE

fall ( Tinetti, Lui, & Claus, 1993) . A falls exercise Summarising the exercise
management programme should retrain or main- evidence
tain the ability to get up from the floor to avoid a
Several trials may have used exercise of insufficient
“long lie” after a non-injurious fall, and include
duration, intensity ( overload) , or frequency to
practice at other coping skills such as summoning
effect change to the person’ s gait or movement
help and keeping warm while on the floor
patterns ( Means, Rodell, O’ Sullivan and
( Simpson, Harrington, & Marsh, 1998; Simpson,
Cranford, 1996; Mulrow et al., 1994) . Other trials
Marsh, & Harrington, 1998) .
have used a general exercise class aimed at seniors,
There is considerable interest in exercise as an
which may not have been sufficiently specific to be
intervention to reduce osteoporosis ( Rutherford,
effective ( Lord, Ward, Williams, & Strudwick,
1997) . It appears that regular physical activity is
1995, Reinsch, MacRae, Lachenbruch, & Tobis,
the most important preventative measure against
1992) . Trials that have been unsuccessful in show-
hip fractures, with the risk among those who take
ing a risk reduction with exercise have often relied
regular activity being halved ( Law, Wald, & Meade,
on the individual’ s recollection of falling rather
1991) . Therefore it is important to consider the
than collecting falls data prospectively. Also, in
inclusion of bone-loading exercises in the design
some trials the criteria for what constitutes a fall is
of a falls management strategy.
not clearly defined. In these circumstances, the
Exercise should be considered not only as a
answer to “How many falls did you have in the last
means of reducing falls but also of reducing fear of
year?” can give inaccurate data. Finally, many trials
falls and depression, both of which are common
failed to target their subjects and included
amongst fallers ( Tinetti et al., 1994) .
non-fallers in the study ( Reinsch et al., 1992;
McMurdo, Mole, & Paterson, 1997, Means et al.,
1996) . As exercise must be specific to the task, if
the subjects did not fall before the trial then a
RATIONALE FOR THE FALLS change in fall status is difficult to gauge. For effec-
tive falls management, the exercise must be set at
MANAGEMENT EXERCISE
sufficient intensity, duration, and frequency and
PROGRAMME (FaME) work with a targeted population group. It also
needs to be specific.
Development of the FaME
Programme
The FaME programme has been designed to take
Specificity
account of both positive and negative outcomes Specificity of training is important not only to ath-
relating to falls, within the scientific literature. A letes but also to older people. It is possible to
progressive tailored programme had to be evolved improve quadriceps strength in women aged over
that would be sufficiently specific, functional, and 75 years by nearly 30% in just 12 weeks ( Skelton,
of ample intensity, frequency, and duration to be Young, Greig, & Malbut, 1995) without seeing
effective in reducing risk factors, actual risk, and major improvements in functional ability. But
the fear of falls. Also it had to encompass the wide when exercise mimics functional moves, consis-
range of baseline fitness and mobility levels seen tent improvements are seen in most of the func-
amongst the subjects at the start of the pro- tional tasks assessed before and after training
gramme. Injury prevention was a priority. The ( Skelton & McLaughlin, 1996) . One long-term ( 10
programme is arranged in three phases, utilising a year) follow-up of regular walkers also showed the
combination of home-based and supervised ses- importance of specificity, for although the health
sions. It also aims to reflect the current evidence of the walkers was better than those who were sed-
on overcoming barriers to exercise and ways of entary, there was no significant reduction in the
improving long-term adherence in older people number of falls they had compared to the group
( Finch, 1997) . who stopped regular walking ( Pereira et al., 1998) .
 PHYSIOTHERAPY THEORY AND PRACTICE 109

Another 1 year study showed no difference in the safety concerns at the lack of supervision are
muscle strength, body sway, or fracture rate follow- adequately addressed. Campbell et al. ( 1997) used
ing an unvarying non-progressive bone-loading an individualised approach, with adequate initial
home-based exercise programme, designed to instruction on exercise postures. They made tele-
improve strength, faulty posture, and phone contact regularly to maintain motivation
co-ordination ( Kerschan et al., 1998) . Some previ- and monitor progress. At 1-year follow-up 42%
ous exercise trials have not found a significant were still doing at least three sessions of exercise a
decrease in risk of falls, even when there has been week.
improvements in some of the measured risk fac- The majority of effective exercise studies have
tors such as strength ( Hornbrook et al., 1994, used supervised sessions. Qualitative research on
Buchner et al., 1997) , or postural hypotension older people showed that the social aspects of a
( Millar & McMurdo, 1999) . class format were a prime motivator for older exer-
The need for specificity was seen in a large cisers ( Finch, 1997) . Belonging to a group seems
series of randomised, controlled trials called the to promote better adherence to exercise in the
FICSIT programme ( see Piotrowski Brown in this community following a research trial. A supervised
issue, Province et al., 1995) . Seven USA sites class also seems to allow faster progression of train-
addressed the effects of interventions on the rate ing, greater individual feedback, a secure environ-
of falls. Each site used different combinations of ment, peer support, an opportunity for social
intervention, some used exercise, others made interaction, acceptable touching, and a reduction
modifications to other risk factors ( i.e. environ- in feelings of isolation ( Young & Dinan, 1994) .
ment, medications) , some did both. Tinetti and The psychological and health benefits of a regular
colleagues ( 1994) used a range of interventions class environment should never be ignored in
including falls assessment, medication review, preference for a seemingly more cost-effective
exercise, and assessment of risks in the home, to intervention ( Young & Dinan, 1994, Nicholl et al.,
reduce several risk factors for falling and suc- 1994) . A class provides a valuable opportunity for
ceeded in reducing both the fear of falling and weekly reporting back, and reinforcement of exer-
actual falls by 30%. When all the FICSIT site inter- cise technique and intensity, all of which help to
ventions were pooled the exercise groups had an sustain adherence and effectiveness of the home
estimated 10% lower risk of falling than the con- exercise sessions. The home exercise sessions are
trol groups. When allocated into categories of utilised as a method to maintain regularity of
exercise intervention ( balance, strength, endur- strengthening and flexibility exercises.
ance) , the four sites that looked at balance training It seems sensible to utilise both home and
found a 25% reduction in the risk of falling ( Prov- supervised sessions to enhance effectiveness,
ince et al., 1995) and one site that looked at Tai safety, and adherence in a falls management strat-
Chi found that it delayed the onset of the first or egy. Telephone support may also be important in
multiple falls by 47.5%, significantly better than the early days of the programme.
computerised balance training or no exercise
( Wolf et al., 1996) .
The specificity of training will, therefore, dic-
Reducing the risk of falling during
tate the exercise response. Fall management
exercise
requires a constant overload stimulus that stresses The foremost worry for any health professional
the systems involved in the control of balance, working with unstable older people is that the
both static and dynamic. person falls whilst exercising. A recent trial consid-
ering the effect of brisk walking on osteoporosis
found that the cumulative risk of falling while walk-
Supervised sessions, home-based ing was higher in the intervention group
sessions, and telephone contact ( Ebrahim, Thompson, Baskaran, & Evans, 1997) .
No fall-related research has compared home and Qualified, experienced exercise practitioner
supervised sessions. Home exercise is effective if supervision together with a graded strengthening
110 PHYSIOTHERAPY THEORY AND PRACTICE

and walking programme prior to commencement the water, may render this option inaccessible for
of walking outdoors may contribute to better out- many in this vulnerable group ( Finch, 1997) .
come measures. Tai Chi is another way of increasing confidence
For many older people, fear of a further or by reducing fear of falling ( Wolf, Barnhart, Ellison,
more injurious fall tends to constrain movement & Coogler, 1997) . This may be due to its com-
and may limit exercise gains during a supervised bination of safe, tranquil, achievable, low impact
class. One method of reducing injury risk during moves, improved breathing patterns, and increased
supervised and unsupervised sessions is the use of feeling of well-being ( Kutner et al., 1997) .
the hip protector underwear SAFEHIP ã 1. Hip
protectors have been shown to reduce hip frac-
tures by 50% in nursing homes but were worn
Balance training
infrequently ( Lauritzen, Petersen, & Lund, 1993) . Balance training has been shown to be more effec-
A new design of hip protector has shown a better tive than a general exercise class at reducing the
user rate of 73% in orthopaedic patients aged 74 risk of falls ( Province et al., 1995) . Tai Chi, in addi-
and over in Denmark ( Lauritzen, Hindsø, tion to offering safety and fear reduction, appears
Askegaard, & Sonne-Holm 1996) . They are also to be extremely effective at enhancing postural sta-
effective in a community setting ( Villar et al., bility ( Wolf et al., l996, 1997; Wolfson et al.,
1998) . However, their use in allowing safer, more 1996) .Tai Chi-based exercise may be effective for a
effective exercise in a supervised environment is number of reasons. Forrest ( 1997) showed that fol-
one that is not being adopted to full potential, lowing Tai Chi training there is “counterintuitive
considering the confidence they give to the reduction in anticipatory postural adjustments
teacher and the exerciser to work harder. and greater stability of standing posture”. Forrest
Currently, within the FaME programme, about interpreted this as a greater use of the elasticity of
70% of the women wear hip protector pads during the peripheral structures ( involving muscles, liga-
the exercise sessions. ments, and tendons) . Tai Chi has also been shown
Another way to reduce risks and fear during to delay the onset of the first or multiple falls, it
exercise is to work in a low-risk environment. One does not, however, appear as efficient as comput-
study looked at exercise in water ( Simmons & erised balance training at reducing sway ( Wolf et
Hansen, 1996) . They considered two exercise al., 1997) .
groups, one “water-based” and one “land-based” The three-dimensional continuous, controlled,
both of which exercised for 5 weeks. The repetitive nature of the Tai Chi movements,
“water-based” group increased their functional together with the change of head and eye position
reach to a greater extent than the “land-based” and weight transference may be significant in
group ( Simmons & Hansen, 1996) , probably improving postural stability. It should also be
because of the increased confidence and reduced noted that these specific components of move-
fear of a fall allowing larger, more dynamic move- ment are also seen in Hatha Yoga, Chi Kung, and
ment during the exercise. Water-based exercise can slow dance sequences ( adage) .
greatly reduce risk and anxiety, changing water The growing interest in Tai Chi must be tem-
depth can allow progression of resistance, and pered with caution. To be most effective Tai Chi
warm water increases muscle efficiency ( Lord, should be considered as part of a comprehensive
Mitchell, & Williams, 1993) . But adverse elements falls management strategy rather than being advo-
such as inability to swim, pools that are too noisy cated as the only exercise form. Ideally, Tai Chi
and/or too cold for comfort, slippery pool sides teachers, like all exercise practitioners, should be
and inadequate safety on entry into and exit from trained and experienced at adapting the moves for
older people and, when working with fallers,
should have awareness of the safety issues relating
to this vulnerable group. Health professionals
1SAFEHIP hip protector pads, Robinsons Health Care, should ensure that current exercise warm-up and
01246 220022 cool-down guidelines ( American College of Sports
 PHYSIOTHERAPY THEORY AND PRACTICE 111

Table 1
Exercise training strategies

Fitness components Programming guidelines

General population
Strength/power/bone Qualified instructors
Endurance Effective: intensity, duration
Flexibility Regular
Balance/co-ordination Specific
Balanced
Individually tailored
Progressive
Educational
Enjoyable
Active lifestyle approach
Older people
All of the above plus targeted exercise
Bone loading (m ain fracture sites) Specialist instructors
Functional, postural, and pelvic floor muscles Home-based programm es
Co-ordination, balance, and reaction tim e Utilise touch
Body managem ent in everyday situations
Correction of muscle imbalance and asymm etry
Relaxation techniques
Opportunities for socialisation
At any age, the aim of a Physical Training Programme must be to achieve a training effect. To do this
it must include all the components of fitness and follow recommended programming principles.

Medicine Position Stand, 1998a) are being ( Table 1) . In addition, however, there are specific,
observed and additional strength, stretching, bal- progressive falls management strategies that
ance, and bone-loading work are advocated. attempt to bring together the evidence in a com-
prehensive programme ( Table 2) whilst ensuring
that safety and comfort have the highest priority.
These strategies could easily be included in spe-
COMPONENTS OF THE FaME cialist seniors’ sessions once disseminated to
appropriate health and exercise professionals. A
PROGRAMME
glossary of technical terms is to be found in Box 1.
The FaME programme includes the basic fitness The programme utilises a combination of
components and programming adaptations that supervised group and self-directed home-based
would be seen in any seniors’ exercise class sessions supported by structured telephone

Table 2
Exercise training strategies for accident prevention

Falls m anagem ent in older people

All the Fitness com ponents and principles for older people plus progressive programm ing of
Tai Chi adapted m oves Specialist falls m anagement instructors
Open, closed, and backward chain exercises Balance of supervised home-based sessions
Functional and floor work Telephone follow-up
Postural and gait training Pre-/post-fall coping strategies
Supported balance work Accident prevention education
Supported endurance work Opportunities for falls specific group discussion/
Tasks to improve kinesthetic awareness feedback
Tasks to improve visual, vestibular, and `Befriender’ system
sensory input Liaison with physiotherapist and primary health care
Wide variety of static and dynamic balance professionals
Confidence building
112 PHYSIOTHERAPY THEORY AND PRACTICE

Box 1
Glossary
Fartlek training approach A variation in pace, e.g. a burst of faster movement alternating with
a passage of more moderate action, to avoid undue fatigue.
Compound exercises Multi-joint exercises.
Bone-loading work Weight-resisted exercises, e.g. weight training, impact work, etc.
Functional floor capacity Exercises to increase floor confidence, e.g. crawling, getting up
and down, fitting a plug, cleaning the skirting boards, etc.
Periodised Programmed progression over period of time using specified
increments and combinations of intensity.

contact. The home-based sessions are aided by an individualising or “fine tuning” the programme to
exercise booklet ( taking exercises from two meet the diverse levels of ability, medical condi-
specific books: Skelton, 1998; Sharp & Dinan, tions, and exercise and training response found
1996) in large print with illustrations of the correct within the study subjects.
technique for each exercise. Each exercise is Although balance, strength, flexibility, and
taught and checked for correct technique during movement training are the core of the
the supervised class. Qualified specialist seniors’ programme, specific low-impact endurance train-
teachers with additional falls management train- ing is included. This is not only because of the
ing, together with Hip Protectors worn during the health benefits of reduced cardiovascular risk,
class, were considered essential to keep risks to a decreased risk of postural hypotension, improved
minimum. Quality and consistency is assured energy, vitality and sleep, and possible reduction
through regular monitoring and training by in the need for medication ( Dinan & Messent
research staff. 1997) , but also because the authors feel it has spe-
The programme aims to provide repeated, cific balance assets such as improving gait, motor
varied, progressive opportunities to integrate the control, reaction times, dynamic body manage-
balance systems. The exercise strategies have ment, range of movement, and self-confidence.
evolved around a four-point plan to:

1. Increase balance.
Warm-up/endurance/cool-dow n
2. Increase functional capacity. The FaME programme, whilst falls-focused,
3. Increase bone and muscle mass. attempts to take into account special consider-
4. Increase confidence ( reduce fear of falling) . ations necessary for working with vulnerable older
people ( see Table 4) ( Young & Dinan, 1994) , and
The progression is arranged in the three phases, also staying comfortably within the American Col-
which have been named: lege of Sports Medicine’ s ( 1998a) guidelines for
cardiovascular exercise for older people.
1. “Skilling up”—weeks 1–11. As with all seniors’ sessions, adaptations to
2. “Training gain”—weeks 12–33. structure and content are important for the safety
3. “Maintaining the gains”—weeks 34–38. of the participants. These include a longer
warm-up and cool-down period; greater variation
The names of the phases act as indicators to the of pace; the integration of stretches with strength-
exercise content, programming principles, and ening exercises to give active rests; and the exten-
ongoing assessment of each individual’ s progress. sive use of supported balance work. Further
These guidelines ( see Table 3) are, however, only examples of adaptation are the exclusion of steps
guidelines and careful attention is paid to with a high risk of falling ( e.g. cross-steps) ;
 PHYSIOTHERAPY THEORY AND PRACTICE 113

Table 3
Progressive Falls M anagement Programme

“SKILLING UP”
Weeks 1–2
Aim To improve neurom uscular function, technique, and safety during exercise
Equipment Chairs and theraband (elastic resistance bands)
Warm-up 18–20 minutes (including stretches and rewarm er)
Workout and cool-down 15–20 minutes (including chair walking, local muscular endurance, seated and chair
supported sw ay work, seated flexibility for selected muscle groups and Tai Chi)
Weeks 3–11
Aim To improve progressively neuromuscular adaptation, lower and upper lim b
strength, postural alignm ent, and gait technique
Equipment Chairs and harder resistance therabands, hands balls, and large soft footballs, m ats
Warm-up 15 m inutes (including standing work and stretches, pelvic mobility, additional
flexibility stretches)
Workout and cool-down 20–30 minutes (including strengthening for quadriceps, hamstrings, gluteals,
abductors, erector spinae, transverse abdominus, ankle dorsiflexors, and
supraspinatus plus supported standing, functional (e.g. sit to stand); increasing
intensity and duration of supported endurance work and/or dynamic balance,
weight transference, walking forwards, marching to change direction, side
stepping, functional reach in sitting, hand–eye co-ordination, standing Tai Chi
basics, and relaxation)
Dem onstration How to get up off the floor safely
“TRAINING GAIN”
Weeks 12–23
Aim To improve functional ability through progressive resistance and flexibility training,
dynamic balance and sensory input, transition to free standing, and travelling
Equipment Chairs (sam e as weeks 3–11, harder resistance bands, hand-weights and large
balance ball, steps)
Warm-up 15 m inutes (including standing work, chair, and standing stretches)
Workout and cool-down 35–45 minutes (including circuit, speed play, Fartlek “ big body movements” , longer
stride, faster pace shuffle walking, quarter turns, lunges, step on and off and
backwards, sensory stations, introduce floor activities in stages, progress weights
to m uscle failure where possible, developmental stretches, Tai Chi)
Dem onstration Safe, effective floor work principles
Weeks 24–33
Aim To improve transition to multisensory skills, further increase strength, improve/
maintain bone density, improve functional balance capacity
Equipment As weeks 12–23, harder resistance bands, heavier weights
Warm-up As weeks 12–23
Workout and cool-down 35–45 minutes (as weeks 12–23 plus add repetitions/sets, skill challenges, walking
backwards, different walking surfaces (e.g. m ats), m oving gaze and/or head while
walking forward, increase step height, travelling lunges and squats, functional
reach, balancing on a ball or standing, rolling, crawling in sitting and lying,
forward, in reverse and sideways, post-fall strategies
Dem onstration “ How to fall” is demonstrated but not practised. Recovery strategies are progressed
“M AINTAINING THE GAINS”
Weeks 34–38 (and onwards)
Aim Transition to m ulti-sensory skills, maintain/increase m uscle strength, and bone
density, increase frequency, intensity, tim e and type of challenges
Equipment As weeks 24–33
Warm-up As weeks 24–33
Workout and cool-down 35–45 minutes (adding skill challenges, increasing m oves, walking different surfaces
(objects under m at), moving gaze and head while walking (in a line, circle,
square) and squatting, increase step height, build step m ountains, introduce
incline walking, propulsive/rebounding/springing actions if appropriate; also
“scramble” principle, gam es approach, line and diam ond circuits, safe agility
challenges, progress back extension work (i.e. four sets of at least five repetitions
and prone functional abdom inal work, functional reach on the move, standing
resistance without chair, progress Tai Chi)
Fit talk Future recreational exercise opportunities, link system with participants
114 PHYSIOTHERAPY THEORY AND PRACTICE

Table 4 “skill-up” ( Table 3) , longer standing sections are

Special considerations for a “falling” group
added. The standing endurance work is signifi-
Considerations cantly adapted, being chair or wall supported at
More individualised first; participants are encouraged to work with two
More progressive hands supporting, then one, then fingertips and
Focus on compliance vs. intensity issues
Injury prevention the highest priority finally, after perhaps months for some, to work
Continual skilled observation—watch for dizziness, without support but with the chair still well within
overheating, undone laces, m isalignm ent reach. Low impact moves form the basis of the
Hazards—more attention to environment
Protection—chairs, m ats, and hip protector pads endurance training, e.g. controlled knee lifts ( rais-
Class location and facilities ing the foot 1–2 inches off the floor initially and
Practice emergency procedures (who calls 999, fire increasing the range to 90° hip flexion as skill
escapes, ice packs, etc.)
Know fall, fracture, cognitive impairment, and improves) , marching on the spot, hip extension
cardiovascular status and abduction, marching away from and back to
Constant feedback on change of health and exercise the chair and, finally, once confidence and skills
effects
Social interaction, peer support and “fall are improved, backwards walking. Lateral moves
management” talks such as side-steps are used as soon as possible to
Fall and fracture additional teacher training essential increase proprioceptive input from the hip joints.
Although the full range of options is demon-
strated, the teacher performs mainly the lower
option to motivate less able participants. The exer-
biomechanically unsound exercises ( e.g. abdomi- cises are performed at circuit stations arranged in
nal curl ups) ; and longer time in the seated posi- lines, rectangles, circles, and semi-circles as well as
tion following prone or supine lying to allow for the more traditional group format of the teacher
regulation of blood pressure. sitting at the front of a class. A Fartlek training
In every phase of the programme, the warm-up approach ( speed play) is utilised to accommodate
starts with mild, rhythmical, low-tension walking the lower anaerobic thresholds found in older
either standing or chair-based prior to mobilising people. This allows participants to continue for
the joints, rehearsing skills, and increasing longer without undue fatigue ( Table 5, Box 1) .
demand on the heart and lungs before finally The transition to free-standing and/or partial
stretching the muscles. Particular care is taken to support whilst performing dynamic travelling
rewarm at a slightly brisker pace after the stretches moves is viewed as a significant progression, i.e. a
and before the endurance and resistance training “training gain” ( Table 3) . When first introduced,
begins. Cool-down consists mainly of slow rhyth- intensity and duration will almost invariably need
mic exercises to preserve venous return as muscle to be adjusted for a week or two until confidence,
and skin vasodilatation gradually return to resting stability, and endurance are restored. Endurance
levels, but also incorporates held stretches, sway training progress continues in the final “maintain-
and other balance training methods, functional ing the gains” phase through the use of an
activities, additional chair and floor body manage- increased variety of pace, intensity, transition, spa-
ment exercises and, finally, an adapted Tai Chi tial and floor patterns, and the inclusion of travel-
sequence. Many of the activities relate closely to ling compound exercises ( e.g. squats) to
lifestyle and to maintaining independence. challenge dynamic balance as well as endurance.
Longer recovery time is given to remobilising activ- An endurance training range of 55–70% of
ities at the end of a class to reduce the risk of a heart rate reserve ( HRR) , three to four times a
post-exercise fall. week, for 5–20 minutes is recommended by the
In addition to these adaptations specific to American College of Sports Medicine ( ACSM)
seniors, there are falls-management design modifi- ( Table 5) for older adults. It is generally acknowl-
cations. Initially, in weeks 1–3, the majority of the edged that with the levels of deconditioning and
warm-up, cool-down and endurance training is frailty found among many older people in general,
performed on a chair and then as the groups and fallers in particular, together with the fact that
 PHYSIOTHERAPY THEORY AND PRACTICE 115

Table 5
Resistance training and endurance guidelines as part of the Falls M anagement Programme

“Skilling up” “ Training gain”

Initial intensity Progressive intensity Progressive intensity
Approxim ately 4–6 weeks Approximately 7–11 weeks Approximately 12 weeks onward
No m uscle failure No muscle failure To voluntary m uscle failure
12–13 RPE * (somewhat hard) 14–16 RPE* (hard) 14–16 RPE* (hard)
Low to moderate intensity Moderate intensity Vigorous intensity
Approxim ately 45–60% MHR Approximately 55–70% MHR Approximately 55–80% MHR
10–11 RPE* (light to moderate) 11–13 RPE* (moderate to 14–16 RPE* (hard)
som ewhat hard)
Particular care is taken:
l When performing knee extensions or exercises that use the rotator cuff, particularly shoulder abduction, also w hen progressing

to higher w orkloads and new exercises.

l To ensure leg strength is established prior to free standing lunge and squatting actions

l To ensure safe content (e.g. cross steps, pivot turns, high impact w ork are excluded)

Towards the end of the study some medium impact, “propulsive” , “ rebounding” and “ springing” or heel drop activities may be
included only if adaptation has occurred, technique is maintained and there is no contraindication (e.g. arthritis, hip replacement,
etc.)
Adapted from American College of Sports Medicine Position Stand (1998a and 1998b)
MHR, maximum heart rate, RPE, rate of perceived exertion.
* Borg, 1982.

many older people are newcomers to exercise, an were important for a combination of postural con-
even lower starting point may be advisable ( Table trol, improved gait and respiratory function, func-
5) . Intensity of both resistance and endurance is tional floor capacity, and targeted bone loading
monitored through rate of perceived exertion work. This includes specific strengthening work
( RPE) , a self-assessment scale that accommodates for the erector spinae ( sacrospinalis) , trapezius
the greater individual variation in heart rate ( upper, middle, and lower) , rhomboids, latissimus
response to exercise and to training that results dorsi, abdominals ( rectus abdominus, internal
with the ageing process ( Borg, 1982) . With train- and external obliques, and, in particular, trans-
ing in the use of the scale a person learns to listen verse abdominus resulting in co-contraction of the
to and act on their body’ s responses to exercise. multifidus muscle) , iliop psoas and piriformis,
The endurance programme aims for an RPE of supraspinatus, triceps ( at different rates of con-
around 10–11 ( light to moderate) for the first 6 traction) , and wrist extensors and flexors.
weeks, then 12–13 ( moderate to somewhat hard) Strength-training progression must be slow ini-
up to 11 weeks, and then 14–16 ( hard) in subse- tially to avoid excessive muscle discomfort ( espe-
quent weeks ( Table 5) . cially in the early stages of exercise) , to allow time
for muscle and soft tissue adaptation, and to avoid
demotivation ( Kramer & Harman, 1998) . Fallers
Resistance training often have such low baseline strength that gains
Guidelines produced for physiotherapists and will be apparent quickly, so although the ultimate
occupational therapists working with older people goal is to use heavier loads ( to activate the high
who have fallen suggest strengthening the muscles threshold motor units important to muscle
around the hip, knee, and ankle. ( Simpson, power) , it is important to progress slowly and
Harrington, & Marsh, 1998; Simpson, Marsh, & increase duration between sets and sessions if sore-
Harrington, 1998) . Campbell et al. ( 1997) trained ness is reported.
the hip extensors and abductors, knee flexors and A starting point of one set of 10–15 repetitions
extensors including inner range quadriceps, ankle of 8–10 exercises, performed two to three times a
plantarflexors, and dorsiflexor muscles. The week at 30–40% of one repetition maximum
authors felt that certain additional muscle groups ( 1RM) is recommended by ACSM ( Table 5) for
116 PHYSIOTHERAPY THEORY AND PRACTICE

older adults. To promote adaptation and decrease Multiple-task practice,

the risk of injury, older adults just beginning an co-ordination and reaction speed
exercise protocol should stop after 10–15 repeti-
One of the strong predictors of fall status is the test
tions without going to voluntary muscle failure.
“stops walking when talking” ( Lundin-Olson,
After 12 weeks of training the participants can
Nyberg, & Gustafson, 1997) . Obviously, multiple
begin to progress to voluntary muscle failure
tasks performance becomes much harder with
unless they are unable or unwilling. Two or three
disuse, older people tend to avoid doing more
set protocols are used to target specific areas.
than one thing at once. Indeed, one study showed
The FaME programme is periodised in a non-
that those people taking significantly different
linear way as the variation in intensity and volume
times to perform the timed up and go and then the
allows for greater fun and better recovery from
timed up and go carrying a glass of water were
higher levels of fatigue than a programme period-
more prone to falls ( Lundin-Olsson, Nyberg, &
ised with a set intensity and volume ( linear) ( Box
Gustafson, 1998) . In our opinion the only way to
1) . Progressive resistance elastic bands ( which
retrain multiple task performance is to practise it;
appear more acceptable, at the start of a regimen,
even the most unlikely skills such as patting the
than free weights to sedentary older women) are
head and rubbing the tummy at the same time,
used throughout the programme with a transition
become possible with practice. Even in the
to hand weights for upper body exercises in the
“skilling-up” section, where basic techniques are
“training gain” and “maintaining the gains”
being mastered and the work is relatively simple,
phases.
we deliberately bombard the exercisers with multi-
Technique and the importance of responding
ple tasks during the session. For example, whilst on
to day-to-day fluctuations in health, energy, mood
a circuit walk around the room the teacher might
and/or alertness are constantly emphasised as
ask all the women to catch up to someone in front
essential for injury prevention and gaining opti-
of them and say hello, or to clap every five steps, or
mal benefits. The rate of perceived exertion ( RPE)
to stop, turn and look to their left, then ahead,
is again used as a guide to exercise intensity, the
then to their right, and then walk on. Progressively
senior participants having been fully familiarised
challenging multiple tasks are filtered into the
with its use in a resistance training context. The
class over a couple of months to assess progress
RPE should be around 12–13 ( somewhat hard) for
whilst at the same time taking care never to over-
the first 4–6 weeks, then rise to 14–16 ( hard) in
stress the exercisers or make them feel uncomfort-
subsequent weeks. Emphasis is constantly placed
able within the class. The multiple task practice is
on being aware of the signs of a muscle reaching
combined with specific exercises to enhance
fatigue ( “burn”, ache, or loss of co-ordination) .
reacquisition of motor skills, co-ordination and
When isometric contractions are used to target
reaction speed, especially hand–eye and foot
particular areas ( e.g. pelvic floor, vastus medialis,
co-ordination.
sacrospinalis, supraspinatus, transverse abdomi-
nus, and wrist extensor and flexor work) it is advis-
able not to hold contractions for more than 5–6
seconds as participants tend to hold their breath at
Functional floor w ork
the same time. This can lead to a sudden, sharp Functional floor work is an essential component of
rise in blood pressure. They are reminded not to the FaME programe. The mat work is a combina-
hold their breath, and are encouraged to count tion of sequenced rolling, curling, crawling
out loud, an effective way of counteracting this actions in sitting, lying and, wherever possible, the
tendency. all-fours position. Tasks such as getting from lying
Additional home practice exercises are recom- to sitting and sitting to lying are broken down into
mended to any women with poor ankle dorsi- small segments that are practised and then put
flexion or plantarflexion, poor foot response, or together and practised repeatedly. Moves are per-
poor movement control in response to formed forwards, in reverse, sideways, and in spe-
instruction. cific floor patterns. For those for whom this is not
 PHYSIOTHERAPY THEORY AND PRACTICE 117

appropriate, chair options are provided. The walking backwards without spilling a drop! The
floor-based activities also include strengthening “maintaining the gains” phase concentrates on
exercises ( see section on resistance training) and a challenging the visual, somatosensory, and vestib-
sequence of stretches ( in supine, full body, ham- ular mechanisms of balance to improve the right-
strings, tensorsascia lata; in prone, quadriceps and ing reflexes, spinal reflexes, and kinesthetic
functional abdom inal work) . awareness ( Table 3) . Home-based exercise is
Techniques of lifting, reaching, stepping on extended with the introdution of the Cawthorne-
and off curbs, and negotiating progressively chal- Cooksey regime of head exercises for vestibular
lenging obstacle courses are discussed, learnt, and rehabilitation ( Dix, 1979) . With age, a person is
practised in a safe environment. Explicit and con- less likely instinctively to know where their body is
stant cross-reference is made to everyday life and in space and this may be why the integrated
how to incorporate certain exercises into daily approach to balance training through Tai Chi
activities. A neutral, lengthened spine, static ( with its controlled, flowing, repetitive, three-
abdominal contractions, and a heel through to toe dimensional weight transferences and head and
brisk walking action are weekly reminders that gaze alterations) has been so effective in falls
seem particularly effective in motivating practice management trials. For study purposes we have
between supervised sessions. adapted the first sequence of Tai Chi Chuan Yang
Style long-form.
Balance improvements can also be made by
Flexibility, posture placing elastic resistance tubing around the waist
while engaged in a normal activity such as reaching
Flexibility ( range of motion) and postural control
for a ball. This obviously needs to be done on a
is emphasised during all training phases. The aim
one-to-one basis and works well in improving skill
is statically to stretch key muscles ( e.g. hamstrings,
and confidence. Any asymmetry can be corrected
rectus femoris, and iliop psoas, gastrocnemius,
by gently pulling the tubing in an opposing direc-
soleus, pectoralis major, external and internal
tion to stimulate the balance mechanisms.
obliques, and latissimus dorsi) three times in the
Gait training is approached in a number of
course of the session. Daily, chair-based stretching
ways. These include correction of walking tech-
is advocated and although initially all stretches are
nique during endurance work; specific, controlled
held for 8–10 seconds, longer, developmental
mobility work for the pelvis ( rotation; anterior,
stretches ( 10–30 seconds) are introduced during
posterior and lateral tilting; pelvic clocks, etc.) ; as
the cool-down of the “training gain” phase.
well as specific strengthening and stretching exer-
cises ( e.g. gastrocnemius and ankle dorsiflexor,
etc.) referred to earlier. These activities are done
Balance and gait in standing, sitting, and lying positions. Coaching
Campbell et al. ( 1997) used balance tasks such as focuses on increasing stride length and improving
walking heel to toe, walking on heels, walking postural alignment, rhythm, and efficiency.
backwards, and sideways, and turning, bending,
stair climbing ( where stairs were available) , and
standing flexibility work. In the FaME, specific bal-
Teachers
ance challenges are introduced towards the end of For the purposes of the study, the teaching team
the “training gain” phase. These include closed are experienced, senior specialist teachers with
chain exercises on progressively unstable surfaces; over 20 hours additional training on the needs of
reaching forward while sitting on a chair then this vulnerable group. Training is revised before
while sitting on a large balance ball, and finally progression to the next programme phase or on
while standing. There are obstacle courses with participants’ request, such as when one group is
changes in surface, height, pace and even lighting, progressing quickly or specific concerns arise.
walks on a straight or curved line with a glass of Quality assurance visits ensure the content is con-
water and, if possible, the ultimate challenge, sistent and sufficiently challenging.
118 PHYSIOTHERAPY THEORY AND PRACTICE

Group discussion about any recent falls is exercise regimen itself still has to be proved effec-
encouraged within the class. Specific exercise tive. The subjective reports are, however, encour-
advice is given by the teacher, if appropriate, to aid aging. At the time of writing this paper, some 30
recovery. women were entering the “training gain” phase of
the trial and 70 women are due to start the “skilling
up” phase over the next 10 months. Subjective
Evaluation Study reporting from both teachers and participants
indicates improved gait, balance, confidence, cor-
The Falls Management Exercise ( FaME)
rection of trips and slips without falls, and reduced
Programme described in this paper is currently
anxiety about falling. To date, there have been no
being evaluated in a research trial being con-
falls in either the supervised or home exercise
ducted at Imperial College School of Medicine,
sessions.
London. The study volunteers are community
This rationale for an exercise programme for
dwelling women, aged 60 and over, with a history
falls management and the exercise protocol itself
of three or more falls in the previous year. Partici-
is presented as a discussion point for further
pants act as their own controls passing through
debate.
three stages of the study: a 10-month control with
prospective fall data collection, followed by a
10-month intervention ( the FaME programme) , Acknowledgements
and finally, a 10-month follow-up period. The The authors would like to thank the specialist teachers
programme had to be designed to encompass the involved in the trial; Claire Dawson, Rachael Fisher, John
range of baseline fitness and mobility levels. It also Young, Tina Scovell, Tina Theophilus, and Laura Gold, also
the women themselves, self-nicknamed “the fallen angels”.
had to maximise confidence and compliance in a They would like to thank Research Into Ageing, Dunhill
group wary of any activities that may lead to a fall. Medical Trust, Barnwood House Trust, and Save and
Although this programme is part of a research Prosper Educational Trust for funding the Imperial College
research trial and also the Central YMCA, Ealing YMCA,
trial, the principles are sufficiently practical to be Queen Moth ers Sports Centre ( Victoria) , and the Royal
applied at local level through appropriate collabo- Free Hospital Recreation Club for their support of the
ration between primary care, health promotion, research trial.
The authors would also like to thank the following people
and exercise professionals. for their detailed comments on an earlier draft of this manu-
script: Professor Archie Young ( Geriatric Medicine Unit,
Edinburgh Royal Infirmary) , Dr Joan Bassey ( Pharmacology
and Physiology Department, Queens Medical Centre,
Nottin gham) , Dr Olga Rutherford ( Imperial College
CONCLUSION School of Medicine, London) , Sian Goldberg and Laura
Campbell ( Physioth erapy Department, Health Services for
With research suggesting that only 11% of carers Elderly People, Royal Free Hospital) , and Angie Avis ( Phys-
implement environmental modifications iotherapy Department, Wandworth Community Team for
people with learning disabilities) .
recommended by occupational therapists after a
30-minute fall risk assessment in a faller’ s own
home ( Buri, Shaw, Dawson, & Kenny, 1999) there
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