LiFE is a tailored programme of embedded balance and strength activities, taught over five home visits with two booster visits. It was designed to reduce fall risk and resulted in a clinically important 31% reduction in the rate of falls compared with the control programme, which involved gentle sham exercise. A 30% reduction in falls is similar to most interventions currently recommended for fall prevention in clinical guidelines. The structured lower limb strength and balance exercises, taught over a similar time frame and prescribed three times a week, did not show significant results, with a 19% reduction in the rate of falls compared with the controls. Furthermore, the LiFE programme was superior in terms of function and participation, providing support that this programme mediates both fall risk and frailty.
LiFE programme participants improved in both static and dynamic balance, showing moderate effect sizes with the strongest effect observed into the high end static balance measure. The structured programme showed a small effect on static balance and a moderate effect on dynamic balance. The importance of balance, as the most important exercise component in mediating fall risk, was highlighted in a systematic review of 44 exercise trials,4
which examined trials in terms of both fall outcome and exercise intensity. Training in control of postural sway seems to affect the vestibular system by improving individual capacity to regain and control balance.30
The functional activities in the LiFE programme also translated into moderate changes in ankle strength. Ankle strength is understood to be a prime factor for an effective strategy for the ankle when a pertubation occurs, and therefore is protective of falls.31
While LiFE showed steady improvements, all programmes made variable gains for knee and hip strength.
Two other exercise programmes to prevent falls have reported physical activity outcomes using the Physical Activity Scale for the Elderly.32
Both reported less deterioration in controls than in the intervention group, whereas we reported an increase in physical activity in both the structured and control programmes, with a small significant effect for the LiFE programme. The strong response from the Paffenbarger measure of energy expenditure for LiFE could be linked to its use of increased physical activity, in particular stair climbing, for many participants. The LiFE programme also had better outcomes than the structured programme on the functional and daily activity measures, with significant and moderate to large effect sizes for LiFE participants. This effect suggests that the LiFE programme could improve functional capacity in frail older people. There might be value in testing whether the LiFE programme and philosophy could be introduced at a younger and earlier stage, to mediate functional decline whether or not a person has experienced a fall.
The LiFE programme is unique and novel; no other interventions have used a tailored approach to embedded exercise with functional activity. We did find three other programmes offering either structured exercise that included functional movement or specific balance tasks that showed positive outcomes. These programmes perhaps lend some support to the effects of the integration component of the LiFE programme.34
Dual tasking LiFE activities include a range of activities and can upgrade balance and strength challenges in small but incremental ways. For some people, these exercises have included ironing while standing on one leg, talking on the phone while heel standing and moving to limits of stability, carrying a tray or drink in a cup while tandem walking, squatting in the supermarket to select an item from a lower shelf rather than bending, and carrying the groceries from the car to the porch while walking sideways. Emerging evidence suggests that a person’s capacity for dual tasking can predict their risk of falls, particularly capacity for tasks that involve gait variability and attention demanding tasks,37
with increased risk for repeat fallers.38
. Furthermore, training in specific dual task activities to challenge balance in older people, undertaken in clinics, has been shown to improve gait stride and variability, and dynamic and static balance. However, these clinic interventions have not been shown to be transferable to novel situations.30
Tailored and embedded activity that aligns with functional conditions and everyday tasks could enhance integration of skills such as task co-ordination, postural control, and spatial processing. Along with physiological changes, these activities could lead to translation of protective skills in other situations. Liu-Ambrose and colleagues39
presented a central benefit model of exercise for fall prevention, arguing that the contribution of attention, dual tasking, planning, and other executive functioning might be just as important as physiological outcomes. The LiFE approach shows that a sole exercise intervention designed to prevent falls can have a clinically important effect on function at the level of participation engagement.40
Adherence was significantly better in the LiFE programme and control group than in the structured exercise programme, which was evident in the detailed frequency analysis over the first six months. All three programmes maintained a good adherence at 12 months, although adherence to the LiFE programme remained superior. All programmes exceeded the 42% adherence reported in the New Zealand Otago trial, which tested a successful exercise programme that was structured and home based.32
The measures of intensity varied for each programme, making an exact comparison difficult. The structured programme in our study had less follow through with the strength component, although our results were still near to the Otago result. In our study, therapists commented that many older participants struggled with the cumbersome nature of the weight cuffs, and we recommend investment in better designs. Many participants in the control group made comments; some liked the gentle exercise and others regarded them as “too easy’ and not meeting their needs.
The lower performance of the structured programme in terms of a falls outcome might also be due to the range of challenge activities and upgrades needing to be enhanced. In addition, recruitment of participants with recurrent or injurious falls resulted in a higher risk group with multiple problems in our study than in the New Zealand Otago trial.32
The control group received less contact time than both interventions, which could have caused a bias, but we saw no difference in the return rates of fall surveillance diaries, so this is unlikely. Also, adherence to the control and LiFE programmes was similar over the first six months, which spanned the interventionists’ follow-up phase. The falls outcome for the LiFE programme was significantly different from controls; however, the higher confidence interval was close to 1, indicating some caution with interpretation of these results, and further research with the LiFE intervention should aim to replicate our findings. The strong outcomes of the secondary measures point to clear mediators of benefit and confirm there was a positive fall outcome. The control group had an intervention that could have diluted the effect of the outcomes. Since the control exercises were gentle, flexible, mostly non-weightbearing, and not upgraded by the therapists, their effect on fall reduction or balance would have been marginal,41
although we did observe some minimal strength improvements.
Our study had a slightly lower sample size than preferred, which could have led to a type II error. If we had greater power to detect a difference, the confidence interval would probably have been narrower. Furthermore, the fall rate was higher than expected, which could also reduce the required sample size. Despite these limitations, we did find statistical significance. The pilot study, matched against a control programme of no intervention, showed a large reduction of falls, adding further support to our findings. A meta-analysis combining the pilot study9
and our current findings gave an incidence rate ratio of 0.63 (95% confidence interval 0.45 to 0.90), using Comprehensive Meta-Analysis software (version 2).
The LiFE programme provides an additional choice to traditional exercise and another fall prevention programme that could work for some people. Functional based exercise should be a focus for protection from falling and for improving and maintaining functional capacity for older people at risk. The programme has many positive outcomes: increased energy to do more tasks, improved function during activities, and enhanced participation in daily life. In a modern world that increasingly relies on increased automation and doing less, the LiFE programme provides a beneficial environment that offers some stressors and complexity. Furthermore, it challenges allied health professionals to expand their focus when working with older people to find opportunities to incorporate balance and strength training into daily life.
What is already known on this topic
- Balance and strength training is known to reduce falls in older adults
- However, less than 10% of older people routinely engage in strength training and is probably lower for activities that challenge balance
What this study adds
- The Lifestyle integrated Functional Exercise (LiFE) programme provides an alternative to traditional exercise for older people to reduce falls, to improve function in doing activities and to enhance participation in daily life
- The LiFE programme demonstrates that having an environment that offers some stressors and complexity is beneficial