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PAPERS: Lesley Day, Brian Fildes, Ian Gordon, Michael Fitzharris, Harold Flamer, and Stephen Lord Randomised factorial trial of falls prevention among older people living in their own homes BMJ 2002; 325: 128 [Abstract] [Full text]

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Old people and physical exercises.

Sergio Stagnaro   (19 July 2002)

Cognitive and Emotional benefits of exercise may mediate fall reduction.

Michael J. Hogan   (20 July 2002)

Specific exercise is the key

Piers W Simey, Dawn Skelton, Susie Dinan, Bob Laventure   (15 August 2002)

Old people and physical exercises. 19 July 2002
Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics Via Erasmo Piaggio N° 23/8, 16037 Riva Trigoso (Genoa) Italy Send response to journal: Re: Old people and physical exercises.	Sirs, Day L. et al. conclude correctly their interesting paper with the statement that, in adults (Australian born) aged 70-84 years, group based exercise was the most potent single intervention tested, and the reduction in falls among this group seems to have been associated with improved balance (1). This represents another clear evidence for the primary role played by physical exercises programme also in aged men. At this point, I would like to underscore , at least, three essential action mechanisms of physical exercise, as a strategy improving health conditions in both health and diseased people (e.g., involved by CAD). First of all, physical exercises, properly programmed, increase Co Q10 production as well as activate mitochondrial Q 10 cycle, e.g., in endothelial cells and muscular – vascular smooth muscle and skeletal muscle – cells. Secondly, physical exercises increase shear stress in microcirculatory bed, and therefore ameliorate endothelial adhesion point distribuition, normalizing nuclear stimulation by means of cytoskeleton proteins. Finally, well- programmed physical exercises enhance blood-flow and consequently regulate tissue pH, conditio sine qua non of physiological receptors sensitivity to catecolamine, insulin, a.s.o. (2,3,4) Sergio Stagnaro MD., Member NYAS. 1) Day L., Fildes B, et al.Randomised factorial trial of falls prevention among older people living in their own homes. BMJ 2002;325:128 ( 20 July ). 2) Stagnaro-Neri M., Stagnaro S., Semeiotica Biofisica: la manovra di Ferrero-Marigo nella diagnosi clinica della iperinsulinemia-insulino resistenza. Acta Med. Medit. 13, 125, 1997. 3) Stagnaro-Neri M., Stagnaro S., La “Costituzione Colelitiasica”: ICAEM- a, Sindrome di Reaven variante e Ipotonia-Ipocinesia delle Vie biliari. Epatol. 20, 239, 1993. 4) Stagnaro S.-Neri M., Stagnaro S., Sindrome di Reaven, classica e variante, in evoluzione diabetica. Il ruolo della Carnitina nella prevenzione del diabete mellito. Il Cuore. 6, 617, 1993.
Cognitive and Emotional benefits of exercise may mediate fall reduction. 20 July 2002
Michael J. Hogan, Lecturer in Psychology NUI, Galway Send response to journal: Re: Cognitive and Emotional benefits of exercise may mediate fall reduction.	On the basis of their comprehensive and well-controlled study, Day et al., conclude that; "The reduction in falls among participants receiving the exercise intervention was associated with improved balance, most prominent on completion of the exercise programme. However, the falls reduction in this group may also have been mediated via social interaction or behavioural change, or both of these, as a result of heightened awareness engendered during the classes." There is ample evidence to suggest that the reduction in falls associated with exercise intervention programmes in the elderly may also be mediated by improvements in reaction times, attentional control, cognitive efficiency and emotional benefits. Much of the physical and psychological decline associated with aging is thought to be closely related to disuse atrophy or "hypokinetic disease", terms used to describe a range of adverse somatic and cognitive changes and functional losses produced by inactivity (Bortz, 1980). Research has shown that aerobic exercise prevents, and may in fact reverse, age-related losses associated with inactivity. Aerobic exercises are those that require continuous and rhythmic use of large muscles for at least 15 minutes on three or more occasions a week, and which increase resting heart rate by at least 60% of heart rate reserve (DeVries, 1975). Aerobic fitness training is accompanied by increased oxygen utilization, indicating more efficient transport and delivery of oxygen to consumer cells (deVries, 1975). Although many older adults are capable of doing aerobic exercises such as walking, swimming, bicycling, or jogging at an intensity to improve fitness level, only 10% or fewer actually exercise at a level sufficient to maintain or improve cardiovascular fitness (Shepard, 1987). Cross-sectional comparisons of simple and complex reaction times of young and old adults reveal that individuals who are habitual exercisers have response times significantly faster than those of sedentary participants, and highly fit older people may be as fast as participants who are 30 or 40 years younger (Spirduso et al., 1983, 1988; see Stones and Kozma, 1996, for a review). Cognitive performance of individuals whose life-styles include vigorous (aerobic) exercise also tends to be superior to that of age-matched sedentary people. Thus, individuals who are aerobically fit perform better than less-fit participants on tests that measure fluid intelligence (Spirduso et al., 1990). These fitness- related differences in response speed and cognition are probably not the result of genetic predisposition for better CNS functioning. Longitudinal studies, although few in number, have demonstrated improvements in critical flicker fusion, reaction time, visuospatial reasoning, successive cognitive processing, fluid intelligence, and memory (Dustman et al., 1984; Ismail & El-Naggar, 1981; Hawkins et al., 1992). For example, Hawkins et al. (1992) examined dual task performance of both young and older adults using measures of attentional flexibility (Keele & Hawkins, 1982), and time-sharing (Hawkins & Presson, 1986), both before and after 10 weeks of aerobic training. Hawkins et al. noted that previous research has found consistent age-related decrements in divided-attention performance. Hawkins et al. hypothesised that age- related decrements in time-sharing and attentional flexibility could be reduced as a function of improvements in aerobic fitness. It was found that older adults showed substantially larger improvements on both tasks than did non-exercise control participants. An issue which has been raised is whether or not aerobic exercise or improvement in cardiovascular functioning is necessary for reduction in age-related psychological changes? To answer this question, the mechanisms underlying the psychological benefits of exercise need to be examined. There is evidence that exercise enhances the activity of monoamines in the brain (Biddle & Fox, 1989; Spirduso, 1983). Spirduso (1983) emphasized the decrease in neurochemical activity which causes alterations in the aging central nervous system (CNS). Spirduso (1983) pointed out the strong relationships between age, dopamine (DA), and Parkinson's disease. Dopamine is decreased in both age and Parkinson's disease, and Parkinson's disease patients are almost exclusively over the age of 55. The relationship between age and slow movement initiation (as in Parkinsonism) seems to be influenced by physical condition so that the maintenance of high fitness can preserve movement initiation speed. Another possible physiological mechanism, especially emphasised for the older population, is the increase in oxygen-transport capacity, blood circulation, and energy supply to different parts of the body (including the brain) as a result of exercise (Dustman et al., 1984; Ismail & El- Naggar, 1981). A further psychobiochemical mechanism which may explain the emotional improvement following physical activity is release of endorphins by exercise. Various endorphins can reduce pain and produce a sense of euphoria. It has been suggested (Biddle & Fox, 1989; Morgan, 1985; Spirduso, 1983) that exercise is associated with increased concentration of plasma endorphins, and so is related to reduced depression and anxiety. Alternative explanations for the psychological effects of exercise do not regard aerobic exercise or improvement in cardiovascular functioning as necessary. According to Powell (1974), physical activity may have a stimulating effect upon the brain due to afferent stimulation from gross muscular movement, primarily from proprioceptive feedback. Further, volitional physical movement has an immensely interactive nervous circuitry involving inputs from spinal, midbrain, and cortical levels of the nervous system which take part in coordinated movement. The involvement of the entire brain in physical activity may be an important factor mediating a positive change in physical, mental and emotional state of elderly persons (Ismail & El-Naggar, 1981) and in the reduction in the incidence of falls (Day et al., 2002). References: Biddle, S.-J., & Fox, K.-R. (1989). Exercise and health psychology: Emerging relationships. British Journal of Medical Psychology, 62(3), 205- 216. Bortz, J., & Braune, P. (1980). The effects of daily newspapers on their readers: Exemplary presentation of a study and its results. European Journal of Social Psychology, 10(2), 165-193. Day, L., Fildes B., Gordon, I., Fitzharris, M., Flamer, H. and Lord, S. BMJ (2002). Randomised factorial trial of falls prevention among older people living in their own homes, BMJ: 325: 128 DeVries, D.-L. (1975). The relationship of role expectations to faculty behavior. Research in Higher Education, 3(2), 111-129. Dustman, R.-E., & et al. (1984). Aerobic exercise training and improved neuropsychological function of older individuals. Neurobiology of Aging, 5(1), 35-42. Hawkins, H.-L., & Presson, J. (1986). Auditory information processing. In K. R. Boff & L. Kaufman (Eds.), Handbook of perception and human performance (pp. 1-64). New York, NY, USA: John Wiley & Sons. Hawkins, H.-L., Kramer, A.-F., & Capaldi, D. (1992). Aging, exercise, and attention. Psychology and Aging, 7(4), 643-653. Ismail, A. H., & El-Naggar, A.-M. (1981). Effect of exercise on cognitive processing in adult men. Journal of Human Ergology, 10(1), 83- 91. Morgan, W.-P. (1985). Psychogenic factors and exercise metabolism: A review. Medicine and Science in Sports and Exercise, 17(3), 309-314. Powell, R.-R. (1974). Psychological effects of exercise therapy upon institutionalized geriatric mental patients. Journal of Gerontology, 29(2), 157-161. Shepard, R. J., Berridge, M., Montelpare, W., Daniel, J.V., & Flowers J. F. (1987). Exercise Compliance of elderly volunteers. Jounal of Sports Medicine and Physical Fitness, 27, 410-418. Spirduso, W. W. (1980). Physical fitness, aging, and psychomotor speed. Journal of Gerontology, 35, 850-865. Spirduso, W. W., MacCrae H. H., & Osborne, L. (1988). Exercise effects on aged motor function. Annals of the New York Academy of Sciences, 515, 363-375. Spirduso, W.-W. (1983). Exercise and the aging brain. Research Quarterly for Exercise and Sport, 54(2), 208-218. Spirduso, W.-W., & MacRae, P.-G. (1990). Motor performance and aging. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (3rd ed.) (pp. 183-200). San Diego, CA, USA: Academic Press Inc. Stones, M.-J., & Kozma, A. (1996). Activity, exercise, and behavior. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (4th ed.) (pp. 338-352). San Diego, CA, USA: Academic Press Inc.
Specific exercise is the key 15 August 2002
Piers W Simey, physical activity lead Wandsworth Primary Care Trust, The Wilson, Cranmer Road, Mitcham, Surrey, CR4 4TP, Dawn Skelton, Susie Dinan, Bob Laventure Send response to journal: Re: Specific exercise is the key	The role of exercise in effective falls prevention has had a mixed press. Profound conclusions have been drawn from research studies with severe limitations, including failure to select fallers, brief intervention periods and exercise of insufficient intensity to stimulate improvement. Many were alarmed by a trial where fallers fell more often after being encouraged to walk(1) - if the authors had prescribed the balance, gait and strength exercises used in New Zealand(2) in advance of walking, this unfortunate outcome could have been avoided. Today scepticism about the true impact of exercise still remains among professionals and decision-makers in the UK. The study by Day and colleagues(3) is a welcome addition to the literature countering this alarmist view. In the UK, the soon to be published Falls Management Exercise (FaME) trial by Skelton and co-workers found that women aged over 65 with a history of falls taking part in prolonged specific group exercise decreased falls by 60%, and injuries due to falls by 75%. Prescribed exercises included those used by Campbell and co-workers(2), as well as dynamic endurance, balance training, floor exercise and coping strategies after a fall. An accredited training course is now available nationally which covers the specific exercises used(4). We felt that it was important to test the FaME findings outside the research environment and so set up a falls and injury prevention exercise service for community living fallers (average age 81 years) in London in January 2000. Participants have significantly improved a number of known functional risk factors for falls and injuries, in addition to significantly enhancing their scores in the SF36 domains of social contact, mental health and change in health. Improvement in functional capacity is also directly relevant to quality of life. As one participant put it: “I can walk upstairs now. I haven’t been able to walk upstairs for four years. I do my exercises every day at home. I know it’s doing me good.” Primary Care Trusts and Social Services Departments are under pressure to promote the independence of their older residents. They would do well not to overlook the broad impact of tailored exercise in this area. Piers Simey physical activity lead Wandsworth Primary Care Trust, The Wilson, Cranmer Road, Mitcham, Surrey CR4 4TP. piers.simey@mswha.sthames.nhs.uk Dawn Skelton senior research fellow University College London Institute of Human Performance, Royal National Orthopaedic Hospital, Stanmore, HA7 4LP Susie Dinan clinical exercise practitioner and research fellow Royal Free Hospital & University College School of Medicine, Pond Street, London, NW3 2PF Bob Laventure consultant older people British Heart Foundation National Centre for Physical Activity and Health, Loughborough University, Loughborough, Leicestershire, LE11 3TU 1 Ebrahim S, Thompson PW, Baskaran V, Evans K. Randomized placebo- controlled trial of brisk walking in the prevention of post menopausal osteoporosis. Age and Ageing 1997; 26:253-260. 2 Campbell AJ, Robertson MC, Gardner MM, Norton RN, Tilyard MW, Buchner DM. Randomised controlled trial of a general practice programme of home-based exercise to prevent falls in elderly women. BMJ 1997; 315: 1065-1069. 3 Day L, Fildes B, Gordon I, Fitzharris M, Flamer H, Lord S. Randomised factorial trial of falls prevention among older people living in their own homes. BMJ 2002; 325: 128. (20 July) 4 Details of the Postural Stability Training module can be obtained from East Midlands and Pennine Training (Tel: 0116 229 5512). Co- developed by Dinan S, Skelton DA & a National Advisory Group. Funded by the Department of Health.