Falls among adults aged 65 yr and older often result in moderate to severe injuries, such as fractures and head trauma, and can increase the risk of premature death (2). Falls also are costly for the individual and society. Regardless of the medical care system that is studied, the economic burden caused by fall-related injuries is substantial for developed countries. In the United States alone, direct medical costs totaled more than $0.2 billion and $19 billion for nonfatal injuries sustained by adults aged 65 yr and older in 2000 (16). In an effort to address these alarming statistics, a large number of randomized clinical controlled trials have investigated the efficacy of a number of different intervention strategies. Among the most promising strategies that have been studied over the last two decades are those that include exercise, either as a stand-alone strategy or core component of a multifactorial intervention approach (3,12,14).
Despite the available research evidence, few group-based exercise programs that specifically targeted balance and mobility existed in community settings in the late 1990s. Moreover, a continuum of community-based exercise programs was not available to older adults other than the healthiest or frailest older adults. It was this perceived lack of specialized exercise programming, coupled with the desire to provide well-designed and competently delivered programs to which health care professionals could direct their patients postdischarge, that served as the impetus for development of the Fallproof Balance and Mobility Program. This article will describe the theory behind the Fallproof program, the multidimensional structure of the program, the accumulating evidence of the program's effectiveness in lowering fall risk, and the tools and processes used to maintain the program's fidelity as it is broadly disseminated throughout the United States and Canada.
Theory Behind the Program
The content and structure of the Fallproof Balance and Mobility Program is derived from the principles embodied in the systems theory of motor control as conceived by Woollacott and Shumway-Cook (23,24) and the ecological theory of perception and the control of bodily orientation (8,9). The systems theory of motor control assumes that multiple systems collaborate to control bodily orientation and locomotion. Whereas certain systems provide the sensorimotor processes that constitute the physiological basis of postural control, other systems (e.g., musculoskeletal, cognitive) constrain an individual's capability for achieving a particular goal-directed action. For example, even though an individual might exhibit above-average sensory and motor function, his or her ability to complete a task might be undermined by an inability to remember how to perform it because of an impaired cognitive system. In another situation, the lack of adequate strength in the lower body might limit an individual's ability to climb stairs or even rise from a chair despite above-average cognition and adequate sensory and motor function. In summary, the theory posits that an individual's inherent capability for successfully completing goal-directed actions is constrained by how well each of these intrinsic systems functions, both in isolation and collaboratively.
In addition to the intrinsic subsystems that both shape and, on occasion, constrain an individual's motor behavior, two additional constraints on action play an important contributing role in shaping the action that emerges. According to the ecological theory of perception and bodily orientation, these include the goals of the action being attempted and the properties of the environment in which the action is to take place (8,17,18). For example, gravitational and inertial forces always are acting on the upright body in any given environmental context. Although the influence of these external forces is minimal when an individual is performing a relatively simple task, such as standing quietly on a broad, firm surface, these forces are magnified as the person begins to perform a more difficult task, such as leaning out over his or her base of support or walking across a slippery surface. One can expect that as the number of intrinsic systems fall below a critical threshold of function, manifesting in balance-related impairments (e.g., muscle weakness, reduced range of motion, sensory loss), the older adult's ability to accomplish a single daily task such as rising from a chair or reaching for objects in cupboards will be compromised. The added challenge of performing a second task simultaneously with the first (e.g., carrying a bag of groceries, engaging in a conversation) will further compromise action because of the need to divide attention between the two tasks. In fact, it has been hypothesized that age-associated changes in the allocation of attention might, in and of themselves, contribute to postural instability and increased falls in certain groups of older adults (15).
Existing environmental constraints (e.g., reduced lighting conditions, the absence of handrails on stairs) contribute one more element of complexity to the task situation and constitute a third important variable that increases fall risk. In recognition of their compromised abilities, older adults often cease to engage in activities they perceive to place them at high risk of falling, or they begin to limit the types of environments in which they are prepared to engage in those activities. Although these self-imposed restrictions on activity decrease falls in the short term by reducing exposure, over the long term, diminished self-confidence and severe physical deconditioning only serves to accelerate the onset of physical frailty and increased fall risk (19). At a practical level, both theories of motor control described here reinforce the need to use multiple and appropriate tests designed to evaluate the integrity of the multiple intrinsic systems known to influence postural control followed by an exercise intervention that specifically targets the multiple-system impairments identified.
The short-term efficacy of the Fallproof program was first demonstrated in 2000 in a laboratory setting (11). A small, randomized, controlled trial was conducted with a group of 45 older adults who had previously fallen to determine whether key risk factors associated with falling could be reduced following 8 wk (twice weekly for 1 h) of individualized training in balance and mobility. The progressive set of balance exercises introduced were designed to systematically manipulate the capabilities of the individual, the task demands, and the environmental constraints as described in both the systems and ecological theory of perception described earlier. The significant improvements evident for both sensory and motor impairment tests conducted as well as two functional tests of balance and mobility provided support for the efficacy and transferability of the program as designed. The program was subsequently translated into a group-based program that could be implemented in community-based settings. A feasibility study was then conducted in 18 senior centers in Orange County, California, with the primary goal being to determine whether this type of program could be successfully implemented and sustained in the community. The results of the 3-yr funded study provided evidence for the program's efficacy and overall sustainability. The effectiveness of the 8-wk version of the group-based program was subsequently compared in a group of 52 older adults (mean age = 78.6 yr) categorized as either high- or low-functioning based on physical activity levels and self-reported ability to perform basic, instrumental, and advanced activities of daily living (20). The results again showed significant improvements for both groups in 9 of the 10 outcome measures evaluated, with the lower functioning group demonstrating greater improvements in those tests measuring sensory integration and reception, balance, lower body strength, functional mobility, and balance-related self-confidence.
Structure of the Program
The overarching goal of the group-based Fallproof Balance and Mobility Program is to promote functional independence by ameliorating or modifying the risk factors that contribute to heightened fall risk among "at-risk" and physically frail older adults. To accomplish this goal, the program includes a carefully selected battery of tests that are used to identify functional limitations emerging from impairments in one or more of the systems involved in the control of balance and mobility. The standardized assessment package includes a measure of balance (i.e., Fullerton Advanced Balance (FAB) scale or Berg Balance Scale), gait (30-ft walk at preferred and maximum speed), upper and lower body strength (e.g., 30-s arm curl and chair stand), balance-related self-confidence (i.e., Balance Efficacy Scale), functional mobility (8 Foot Up and Go test), and attention (i.e., walkie-talkie test). More recently, the walkie-talkie screening test has been replaced with the walking while talking test (21) as a means of more effectively measuring the older adult's ability to divide attention between multiple tasks. A more comprehensive description of each of the tests that comprise the assessment package for this program is provided elsewhere (10).
Consistent with the systems and ecological theories of perception described earlier, the program content is designed to systematically manipulate the demands of the task to be performed and/or the constraints imposed by the practice environment in a way that matches each individual's intrinsic capabilities (Figure). An important goal of the program is to challenge, but not exceed, the individual's intrinsic capabilities by systematically introducing balance and mobility tasks of increasing complexity that are to be performed in a variety of practice environments that simulate those encountered during daily life.
The program content focuses on elevating the function of the sensory, motor, and cognitive systems through four core program components: 1) volitional and nonvolitional control of the center of gravity (COG); 2) sensory reception and integration skills; 3) selection and scaling of postural control strategies; and 4) development of a flexible and adaptable gait pattern. Recognizing the importance of upper and lower body strength, flexibility, and endurance to functional mobility, each of these physical parameters is systematically incorporated into the program and often in combination with many of the balance activities presented in the four program components. For example, upper and lower body strength and endurance are combined with balance activities that are performed against or with resistance (e.g., resistance bands, weighted balls) while seated, standing on stable or compliant surfaces, or stepping up onto and over benches of different heights. Other balance activities, particularly those presented in the COG, postural-strategy, and gait-pattern components of the program, also are designed to improve flexibility of the upper and lower body by requiring movements through a full range of motion.
COG Control Training
The balance and mobility activities presented in this component of the program are designed to improve the older adult's ability to maintain a more upright position in space, lean away from and return to midline with improved postural control, and move the body through space more quickly and confidently. In addition, the exercises are intended to improve selected physical-fitness parameters (e.g., aerobic endurance, strength, power, coordination, flexibility) that contribute to good balance and mobility. These exercises often are called the "belly button" control exercises because they readily conjure up a visual image of what part of the body must be manipulated in order to maintain postural control while performing a variety of daily tasks in a variety of environmental contexts. These exercises are systematically progressed from seated to standing to moving task situations according to each individual's capabilities and the demands associated with the task and practice environment.
It has been well documented that each of the three sensory systems (visual, vestibular, and somatosensory) that contribute to balance and mobility experience significant changes as a function of the aging process. Visual acuity, contrast sensitivity, and depth perception decline; the threshold for detecting vibration and joint movement increases; and the number of sensory receptors (hair cells) in the vestibular apparatus declines. A reduction in the gain of the vestibular-ocular reflex with advancing age also has been documented (10). Although older adults generally are able to compensate for small changes in each of these systems that occur with age, impairments associated with particular medical diagnoses (e.g., macular degeneration, peripheral neuropathy, Meniere's disease) or severe deconditioning will adversely affect their postural-control system and limit both the types of activities they can perform successfully and the environments in which they can function safely.
The activities presented in this component of the program are intended to optimize the functioning of the sensory systems that are not impaired while compensating for the system or systems that are known to be permanently impaired. Gaze-stabilization strategies are emphasized as a means to optimize vision and provide a stable visual target during standing and locomotor activities, first when the head is stable and then when it is moving. Performing balance activities on a compliant or moving support surface also promotes the use of vision for controlling balance by disadvantaging the somatosensory system, thereby making it more difficult to obtain accurate sensory information from the surface. Conversely, in the case of older adults who are identified as visually dependent, balance activities that optimize the use of somatosensory information, particularly at the level of the surface, while making it more difficult to use vision to control balance are preferred. These activities are performed on a broad, firm surface so that both the quality and amount of somatosensory information received are maximized. Reducing vision by having the participant wear sunglasses, or engaging vision by introducing a second task that requires vision (e.g., reading, tracking, reaching for or catching objects) are effective ways to reduce an older adult's reliance on vision to control balance. Vision also can be removed as a sensory input by having participants perform activities with their eyes closed as the program progresses.
Finally, a greater reliance on vestibular input for balance is achieved by disadvantaging the visual and somatosensory systems. Performing a variety of balance activities on surfaces that are compliant and/or moving while vision is either engaged in performing a second task or the eyes are closed requires greater reliance on vestibular information for balance. Of course, knowing which multisensory activities are most appropriate for each participant requires a careful review of the medical history completed at the outset of the program (to ascertain whether certain sensory systems are permanently impaired as a result of an existing pathology) and the results of selected items on the functional tests performed during the preprogram assessment.
The goal of the activities presented in this component of the program is to improve an older adult's ability to select and then appropriately scale the postural strategy that best suits the demands of the task presented or the environment in which it is being performed. As a consequence of age-associated declines in multiple parameters (e.g., muscle strength, flexibility and proprioception at the ankle joint, heightened fear of falling) and the increasing avoidance of certain activities or environments, an older adult's ability to effectively select and/or scale the various postural strategies is often compromised or absent.
At least three clearly defined postural strategies have been described in the postural-control literature (4,7) and are used to either control sway in an anterior-posterior direction or reestablish balance after a perturbation. These are referred to as the ankle, hip, and step strategies. Each of these discrete postural-control strategies and various combinations of them are most commonly used to help us maintain or control our balance while performing daily tasks in and around the home or moving about the community. Not only will the demands associated with the task being performed influence the type of postural strategy selected but so too will the environment in which the task is being performed. Helping the older adult become more efficient in selecting and implementing the most appropriate postural strategy for the task demands and/or environmental situation is the primary reason for incorporating this set of progressive activities into the program.
The ankle, hip, and step strategies each can be practiced by manipulating the task goal or environment in at least four different ways: 1) maintaining balance while standing on different support surfaces (e.g., firm, compliant, moving, narrow), 2) voluntarily swaying farther away from midline in different directions while standing on different support surfaces, 3) minimizing or controlling the amount of sway in response to progressively larger applications of external force, and 4) making subtle and not so subtle adjustments in body position in anticipation of a destabilizing limb movement.
Just manipulating the type of support surface on which an individual is standing often can trigger the use of a particular postural strategy. For example, when one is standing quietly on a firm, broad surface, sway can largely be controlled using an ankle strategy. Performing the same task on a narrow or unstable surface, however, necessitates the need for a hip strategy to maintain balance. This change in strategy is necessary because the surface against which the individual is pushing is more narrow than the length of the feet or the surface "gives" or moves as force is being exerted, making it more difficult to balance using only the smaller muscle groups surrounding the ankle. In people who are experiencing balance and mobility problems, standing on these more difficult surface types can often result in the use of the step as opposed to hip strategy. The use of a stepping strategy might be prompted by a heightened sense of fear as the level of sway increases, a below average region of stability, or the absence of a hip strategy.
Presenting balance activities that require progressively larger movements of the COG through space or greater speed also will facilitate the use of the ankle, hip, and/or step strategy. Swaying over a small distance at a slow speed largely can be controlled using an ankle strategy, whereas swaying over progressively larger distances and at a faster speed will force the use of a hip strategy if the individual is to avoid having to take a step because balance has been lost. Introducing activities that require subtle changes in body position in anticipation of a destabilizing limb movement also provides older adults with an opportunity to practice the different postural strategies. These types of activities might include stepping up and down steps of different heights, stepping over obstacles while walking, maneuvering around cones, or stepping on and off different surfaces. Anticipatory adjustments in body orientation and the full array of postural strategies are necessary when performing these types of activities.
Applying different levels of external force to an individual, particularly if it is unexpected, requires that individual to make a more automatic postural adjustment and, therefore, constitutes the most advanced set of exercises associated with this program component. What one observes, in a person with good balance abilities, is the selection of the postural strategy that best matches the level of force applied. For example, a small application of force (i.e., light push or pull) is usually responded to with a countermovement about the ankle joints. As the level of force increases, the larger muscles in the hip region are recruited because the ankle joints can no longer generate enough torque to adequately counter the destabilizing force.
Finally, a large application of force (i.e., strong push or pull) most often results in a stepping action in an effort to quickly reestablish a good, stable base of support. These activities are progressed from seated, to standing, to moving contexts, depending on the individual's capabilities.
Gait Pattern Enhancement and Variation Training
The ability to successfully move about in a variety of different environmental contexts that impose different timing (e.g., stepping on and off escalators, crossing busy streets) or spatial demands (e.g., stepping over obstacles, walking in crowded malls) requires a gait pattern that is both flexible and adaptable. The activities in this component of the program are designed to achieve both of these goals. For example, directing older adults to start and stop quickly and walk with longer, shorter, or wider stride patterns and in different directions requires them to vary the spatial and temporal characteristics of their gait pattern, making it more flexible in the long term.
Other activities designed to enhance and vary the gait pattern include walking on the toes or heels; stopping, starting, and turning on command; and stepping over obstacles, on and off different surface types, and up and down inclines. As the older adult becomes more confident in his or her balance abilities and demonstrates better overall performance, additional tasks are added systematically to force a more subconscious control of balance because of the need to divide attention between the multiple tasks. To accomplish this goal, activities that require the older adult to count backwards, reach for or catch objects, or turn the head while walking are incorporated systematically into the training program. These activities further challenge each individual's abilities while also rendering the practice environment more like the everyday performance environment.
Individualizing the Level of Challenge in a Group Setting
Although the task of meeting the individual needs of each participant requires more time and effort on the part of the instructor when working with a group of older adults with different functional limitations and system impairments, an individualized approach is made possible in the Fallproof program by manipulating the level of challenge associated with each set of progressions presented to the group. For example, program participants can be performing the same set of weight-shift activities but at different levels of task difficulty, simply by manipulating the type of surface on which they are sitting or standing or the position of their arms (e.g., holding seated support surface, positioned on thighs, folded across the chest) during the exercise. Integral to being able to appropriately challenge each client in the program is the instructor's ability to correctly interpret the results of each test conducted with each client prior to the start of the program. These skills are developed during the course of the instructor-training program that will be described in a later section of this article.
The set of progressive and culminating activities that were designed for each of the four program components are intended to simulate the same types of balance challenges encountered in daily life. For example, repeated opportunities are provided for program participants to experience the challenge of interacting with compliant and moving surfaces, stepping over obstacles, ambulating in busy sensory environments, performing multiple tasks requiring divided attention, and being unexpectedly perturbed. These types of activities simulate daily activities such as walking over uneven terrain, stepping up onto and down from curbs, walking in crowded malls, talking or turning the head to check for oncoming traffic while walking, or responding to the unexpected pull of a dog on its leash. Being able to demonstrate the functional relevance of each activity presented is an important skill needed by the Fallproof program instructor.
Maintaining Program Fidelity
Consistent with the recommendations of the National Institutes of Health Behavior Change Consortium (BCC), a number of techniques and processes have been developed over the past 7 yr that are aimed at retaining the fidelity of the Fallproof program as it is more broadly disseminated throughout the United States and Canada (1). These include the development of 1) an instructor certification program, 2) standardized lesson plans, and 3) a standardized approach to assessing the program's effectiveness. The current Fallproof instructor-training program combines online coursework with a 3-d practical competency exam. The six online theoretical modules provide potential instructors with background knowledge on the risk factors associated with falls, age-associated changes in balance and mobility, the program assessments to be used, and an in-depth review of the four core components of the Fallproof program. Successful completion of the online modules is followed by a 3-d practical competency exam during which each instructor's ability to correctly administer and interpret the program-related assessments and effectively teach a small group class is evaluated. To date, more than 500 exercise specialists and health care professionals (e.g., physical and occupational therapists, nurses) have successfully completed the certification program and now teach the program in community, home, or rehabilitation settings across the United States and Canada. A DVD-based progressive home exercise program comprising three levels also has been developed to supplement the group classes and increase the programming dose received.
Evaluating the program's fidelity was the focus of a recent study conducted in nine community-based centers (13). Specifically, the purpose of the study was to determine whether the instructor training program, combined with standardized treatment delivery and program evaluation methods, would produce a consistent set of positive program outcomes, irrespective of which instructor was delivering the program. Seven certified instructors (e.g., exercise specialists, physical therapists) participated in the study. Multiple program outcomes for 188 older adults (M = 77.63, SD = 7.91) who completed the 8-wk version of the program at one of nine different community centers were analyzed. The results indicated that, across all sites, significant improvements in balance, gait, upper and lower body strength, and balance-related confidence were evident. While participants at some sites demonstrated greater improvements than participants at other sites on some functional performance measures, the mean level of improvement was consistent across all sites. These results demonstrate the importance of instructor training coupled with the development of a standardized assessment and program delivery package.
The Fallproof Balance and Mobility Program continues to evolve as new research findings emerge and the program expands into new settings (e.g., assisted living, adult day health care settings). The group-based component of the program model now has been expanded to 24 wk based on recent research indicating that a minimum of 50 h of targeted balance and mobility training is needed before fall incidence rates are positively influenced (14). The expansion of program content has facilitated the inclusion of more dual-task training in seated, standing, and moving environments and a greater emphasis on gait pattern enhancement and variation training as a means to improve important parameters of gait (i.e., stride length and swing time variability) that have been demonstrated to be better predictors of falls than speed alone (22). Fidelity tools continue to be developed to assess instructor effectiveness and client satisfaction. While the program has been shown to be effective in reducing important risk factors known to contribute to increased falls in the short-term, the program's long-term efficacy with respect to lowering fall rates, fall-related injuries, and health care utilization costs remains to be evaluated. Conducting these studies will be the focus of our future efforts now that the program model has been finalized, a cadre of certified instructors are now available, and the necessary fidelity instruments have been developed.
Well-designed exercise programs that target the intrinsic risk factors associated with increased fall risk have been shown to be effective in a number of randomized controlled trials conducted over the past two decades. With the exception of Tai Chi Chuan (5,6), however, very few other types of exercise interventions studied in the fall prevention literature have been translated into community-based programs and disseminated broadly within the United States. The development, testing, and subsequent dissemination of the Fallproof Balance and Mobility Program in community-based settings was based on a perceived need for specialized programming that could address the needs of older adults at moderate-to-high risk for falls and also provide a community-based resource for health care professionals interested in directing their patients to community-based programs that target balance and mobility skills and are led by well-trained exercise professionals. The Fallproof program model has been tested and refined over the past decade and fidelity instruments developed to ensure that the program is implemented as designed. Future research will focus on evaluating the long-term efficacy of the program in reducing fall incidence rates and injuries, as well as its cost-effectiveness and/or cost-saving capabilities.
Funding provided by the Archstone Foundation, Long Beach, CA to study the feasibility of implementing the Fallproof Balance and Mobility Program in community settings and develop the instructor specialist certification program.
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