Combined exercise is more effective than aerobic exercise in the improvement of fall risk factors: a randomized controlled trial in community-dwelling older men

Abstract

Objective:

To compare the long-term effects of two community-based exercise programs on fall risk factors, such as balance, postural control, mobility and leg strength, in community-dwelling older men.

Design:

Single-blinded randomized controlled trial, comparing three groups, with follow-ups at eight, 16, 24 and 32 weeks.

Setting:

Older men independent-living residing in Maia city, Portugal.

Participants:

A total of 66 older men (aged 69.0 ±4.9 years) were randomly assigned to an aerobic exercise group (n = 22), a combined aerobic and resistance exercise group (n = 22) or a control group (n = 22).

Interventions:

Both community-based exercise programs consisted of three sessions each week for 32 consecutive weeks and were planned for moderate-to-vigorous intensity. The control group had no exercise intervention.

Measurements:

Main outcomes were measured by the Timed Up and Go Test, functional reach test, 30-second chair stand test and 6-minute walk test, on five different occasions.

Results:

Repeated measures of analysis of covariance revealed significant main effects between time × group interaction in all outcomes over time (Timed Up and Go Test: p < 0.001; functional reach test: p = 0.002; 30–second chair stand: p = 0.001; 6-minute walk test: p < 0.001). Both exercise groups reported improvements; however, better performance was identified in the combined aerobic and resistance exercise group compared with the aerobic exercise group (–20.3% vs. –9.1% on the Timed Up and Go Test, +27.5% vs. +10.9% on the functional reach test, +20.8% vs. +7.3% on 30-second chair stand, +10.9% vs. +3.5% on 6-minute walk test).

Conclusions:

Adding resistance exercise to aerobic exercise improves factors associated with an increased risk of falls. However, both exercise regimes, combined or aerobic alone, are more effective than no exercise in the reduction of fall risk factors.

ClinicalTrials.org #NCT01874132

Keywords

Aging community programs resistance exercise risk of falls long-term follow-up

Introduction

The risk of falling increases with age, and this has been associated with identified risk factors as decreases in balance, postural control, muscle strength and changes in walking performance.^1–3 Therefore, fall-risk-factors prevention is an important issue to be addressed in order to limit the related burden and healthcare demand in aging societies.^4,5

Several studies have demonstrated the effectiveness of exercise interventions on the prevention of age-related reduction in functional capacity and health risk factors.^6–9 The majority of exercise-based interventions for older adults are predominately based on aerobic training, which has proven to be effective to improve fall risk factors.^10,11 However, according to the American Geriatrics Society and British Geriatrics Society Clinical Practice, all exercise interventions in community-dwelling older adults for the prevention of fall risk factors should include gait training, resistance exercise and balance training.¹² Indeed, several studies reported the effectiveness of resistance exercise programs to improve the aforementioned fall risk factors.^13–15 Despite the available evidence regarding the benefits of aerobic or resistance exercise to reduce fall risk factors, it is still uncertain if the combination of these two exercise modes has an additive effect in the magnitude of changes of fall risk factors compared with a single exercise mode.

Therefore, the aim of this study was to compare the long-term effects of two community-based exercise programs on fall risk factors in community-dwelling older men. We hypothesized that a community-based combined aerobic and resistance exercise program would produce greater balance, postural control, mobility and leg strength improvements than a community-based predominantly aerobic exercise program.

Methods

The present study was a long period follow-up randomized controlled trial (NCT01874132, clinicaltrials.gov) that evaluated two different community-based exercise programs.

The recruitment of individuals for a nine-month study was made through the records of the City Council (Maia, Portugal) and an invitation to participate was made by telephone. Inclusion criteria included men aged between 65 to 79 years of age, living independently, with no history of previous exercise training or recreational sports practice, and with medical approval for exercise. Exclusion criteria were the following: smoking; severe obesity (body mass index (BMI) ⩾35 kg/m²);¹⁶ grade 3 hypertension;¹⁶ history of falls (defined as an unexpected event that ends on the ground, floor or lower level)¹⁷ and those with neurological, mental or cognitive disorders, and orthopedic, pulmonary or cardiac problems (e.g. arrhythmias, history of angina, myocardial infarction, coronary bypass surgery, valvular disease) that could restrict or preclude their participation in exercise.

Both verbal and written consents were obtained from each participant prior to testing and training; all were informed of the objectives, procedures and potential risk or discomfort. The study was approved by the University of Trás-os-Montes e Alto Douro review board for human subjects (ref. 001.032011), according to the Helsinki Declaration.

Randomization was generated by the software “randomizer.org” and conducted by the main researcher (NS). Patients were block randomized into two treatment groups: Aerobic exercise group or combined aerobic and resistance exercise group; and a control group (each group n = 22). Before starting the intervention, sealed opaque envelopes containing the name of the corresponding group was opened by the instructors who supervised the training programs. All the evaluators were blinded to the study arms. Data were collected from autumn 2013 to spring 2014.

All participants were instructed to continue their normal medication and dietary patterns during the course of the study. Furthermore, participants did not receive any nutritional counseling.

Interventions

Both community-based exercise programs consisted of three sessions each week for 32 consecutive weeks and were planned for moderate-to-vigorous intensity. According to the latest position stand from the American College of Sports Medicine,¹⁸ moderate intensity represents a perceived exertion of 12 to 13 points in the Borg scale of 6 to 20 and a range of 50% to 69% of one repetition maximum (1-RM). The vigorous intensity represents a perceived exertion of 14 to 17 points and a range of 70% to 84% of 1-RM. The average adherence rate to all exercise sessions was 85%; however, the participants were informed that a minimum of 77 sessions during the 32 weeks (80% compliance) was required to be included in the analysis. All participants received two weeks of familiarization sessions with the equipment and exercises to be used in the intervention. All sessions lasted approximately 60 minutes and were always supervised by a professionally qualified instructor.

Aerobic exercise program

The aerobic exercise group trained twice per week in a land environment (Mondays and Wednesdays) and once per week in an aquatic environment (Fridays). All aerobic training sessions consisted of: (i) a 10-minute warm-up period, which included walking and flexibility exercises; (ii) a 30-minute cardiorespiratory period, including walking and/or brisk walking; (iii) a 10-minute muscular endurance, which included three exercises (three sets of 15–20 repetitions) using only bodyweight and gravity for strengthening the lower and upper limbs in a land environment, and water resistance in an aquatic environment; and (iv) a 5-minute cool-down period, which included breathing and stretching exercises.

Combined exercise program

The exercise sessions for the combined exercise group included the same format as the aforementioned. However, the aerobic training session on Mondays were replaced by a resistance exercise session. The intensity of the resistance training sessions was defined by the pyramidal method set to 65% of 1-RM in the first eight weeks; 75% of 1-RM for Weeks 8–24; 70% of 1-RM for Weeks 24–28; and 65% of 1-RM for Weeks 28–32 (three sets of 10–12 repetitions in all sessions). Each session always began with a 10-minute warm-up and ended with a cool-down period. The main part of the sessions consisted of a circuit of seven exercises: bench press, leg press, lateral pull-down, leg extension, military press, leg curl and arm curl, in this order, and carried out with conventional variable resistance devices (PANATTA, Fitline 2000 series, Italy). The 1-RM values were taken at the first workout of Week 1, Week 8, Week 16 and Week 24, and at the last workout of Week 32, allowing periodic adjustment of the resistance training intensity for the combined exercise group.

To control the target intensity of the different training programs, all participants at all training sessions recorded the values of perceived exertion using the Borg scale.

The control group had no exercise intervention, and were instructed to pursue their habitual daily life activities.

Outcome measurements

Each participant reported to the facilities at 7 am, following an overnight fast, on five separate occasions (pretraining, after eight weeks, after 16 weeks, after 24 weeks, and post-training). Height and weight was controlled and measured under fasting on a standard scale with a stadiometer (SECA 770; Seca Corporation, Hamburg, Germany) in a quiet room with an ambient temperature of 22 ºC, and BMI was further calculated using the standard formula: weight(Kg)/height(m)². After breakfast, each participant was assessed blindly and always by the same technicians.

Primary outcomes involved the Timed Up and Go Test,¹⁹ and the functional reach test,²⁰ to assess fall risk related to gait, balance and postural control; and the 30-second chair stand test²¹ and the 6-minute walk test,²¹ to evaluate physical function related to leg strength and mobility.

As it was expected that the combined exercise group participants would increase their maximum strength during the resistance training sessions, 1-RM values of leg press, leg curl and leg extension exercises were also recorded at the first workout of Week 1, Week 8, Week 16 and Week 24, and at the last workout of Week 32, allowing periodic adjustment of the resistance training intensity. The 1-RM test was measured only for the combined exercise group and always by the same instructor.

Statistical analysis

Normal distribution was tested with the Shapiro–Wilk test, and the skewness and kurtosis indices were analyzed. Analysis of covariance (ANCOVA) was used to determine whether significant differences existed between the control and experimental groups in posttest measurements, with baseline measurements used as covariates in the analysis. The effects of time and time × group interaction for BMI, Timed Up and Go Test, functional reach test, 30-second chair stand test and 6-minute walk test were determined by using repeated-measures ANCOVA with baseline as the covariate. A Bonferroni test was used for post-hoc comparisons. For each ANCOVA effect, a partial eta squared (η²_p) was calculated to determine the magnitude of the effect sizes, and interpreted as small (0.08), medium (0.18) or large (0.41).²² Pearson’s correlation coefficient (r) was used to assess the relationship between BMI, Timed Up and Go Test, functional reach test, 30-second chair stand test and 6-minute walk test. The differences in 1-RM percentage gains of leg press, leg curl and leg extension across the resistance training sessions were tested by repeated measures ANOVA.

All data were analyzed using the statistical software IBM SPSS Statistics for Macintosh, version 19.0.0 (SPSS Inc., Chicago, IL), and the level of statistical significance was set at p < 0.05.

Results

Figure 1 shows the flow of participants through the study. A total of 89 volunteers were assessed for verification of eligibility. A total of 55 Caucasian elderly men completed the 32-week study and were included in the analysis. The mean age of participants in each of the three groups was 69.0 ±4.9 years in the aerobic exercise group, 71.3 ±4.6 years in the combined exercise group and 67.2 ±5.5 years in the control group. The average adherence rate to each of exercise sessions was 85% in the aerobic exercise group and 88% in the combined exercise group. The average perceived exertion reported by all participants in all exercise sessions ranged between 11.0 ±2.9 and 12.9 ±1.5 points in the land aerobic exercise sessions, between 13.2 ±0.7 and 13.7 ±0.8 points in the aquatic aerobic exercise sessions and between 13.4 ±1.3 and 14.1 ±1.5 points in the resistance exercise sessions.

Figure 1.

Consolidated Standards of Reporting Trials diagram showing the flow of participants through the study.

Baseline and outcome measures for participants during the study period and at the end of the study are shown in Table 1. At baseline no significant between-group differences were observed in the Timed Up and Go Test, functional reach test, 30-second chair stand test and 6-minute walk test.

Table 1.

BMI, Timed Up and Go Test, functional reach test, 30-second timed chair-stand test and 6-minute walk test measurements for the aerobic exercise group (n = 18), combined exercise group (n = 18) and control group (n = 19) over 32 weeks.

	Measures across time
	Baseline	Week 8	Week 16	Week 24	Week 32
Body mass index (kg/m²)
AEG	27.4 ± 3.7	27.4 ± 3.4	27.3 ± 3.6	27.4 ± 3.9	27.4 ± 3.4
CEG	26.4 ± 2.3	26.7 ± 2.6	26.6 ± 2.4	26.3 ± 2.3	26.4 ± 2.5
CON	27.6 ± 3.2	27.8 ± 3.2	28.2 ± 3.3	27.8 ± 3.2	27.8 ± 3.0
Timed Up and Go Test (seconds)
AEG	7.7 ± 1.1	7.2 ± 0.7	6.9 ± 1.0	6.9 ± 0.8**	7.0 ± 0.8
CEG	7.4 ± 1.0	6.6 ± 1.1	6.3 ± 1.0*	6.1 ± 0.8**	5.9 ± 0.7**
CON	7.5 ± 0.7	7.1 ± 1.3	7.5 ± 1.5	7.5 ± 1.3	7.7 ± 1.3
Functional reach test (cm)
AEG	28.5 ± 6.0	30.2 ± 5.0	30.7 ± 5.6	31.2 ± 6.3*	31.6 ± 6.3
CEG	27.6 ± 5.2	27.1 ± 5.3	29.6 ± 5.6	32.9 ± 5.8**	35.2 ± 5.7**
CON	31.6 ± 6.6	28.7 ± 7.8	28.6 ± 6.0	29.2 ± 6.4	28.9 ± 6.2
30-second timed chair-stand test (repetitions)
AEG	15.1 ± 1.1	15.4 ± 3.3	15.1 ± 2.1	15.1 ± 2.0	16.2 ± 3.8
CEG	14.9 ± 2.1	16.4 ± 3.3	16.8 ± 2.5	16.6 ± 2.8	18.0 ± 2.5
CON	13.8 ± 1.9	14.4 ± 2.9	13.5 ± 1.8	13.1 ± 2.1	12.9 ± 2.1
6-minute walk test (meters)
AEG	559.6 ± 47.0	571.4 ± 48.2	573.6 ± 52.6	581.1 ± 56.2*	579.1 ± 50.0*
CEG	565.4 ± 81.6	582.3 ± 75.8**	618.6 ± 68.8**	617.7 ± 69.6**	627.3 ± 63.6**
CON	571.1 ± 60.7	566.7 ± 57.0	566.8 ± 57.0	568.2 ± 64.3	551.9 ± 67.9

Significant different from baseline, p < 0.05; **Significant different from baseline, p < 0.01.

Note: Values represent means ± standard deviation.

AEG: aerobic exercise group; CEG: combined exercise group; CON: control group.

Repeated measures ANCOVA revealed a significant main effect of time in the Timed Up and Go Test, functional reach test and 6-minute walk test (p = 0.001, p = 0.018 and p = 0.011, respectively), and a significant main effect of the group in the Timed Up and Go Test, 30-second chair stand test and 6-minute walk test (p = 0.036, p < 0.001 and p = 0.045, respectively). Repeated measures ANCOVA also revealed significant time × group interaction in all outcomes (Timed Up and Go Test: p < 0.001, η²_p = 0.579; functional reach test: p = 0.002, η²_p = 0.292; 30-second chair stand test: p = 0.001, η²_p = 0.312; 6-minute walk test: p < 0.001, η²_p = 0.371). Table 2 shows the summary of the repeated measures ANCOVA and η²_p effect sizes.

Table 2.

Repeated measures ANCOVA with baseline as the covariate, and η²_p effect sizes for BMI, Timed Up and Go Test, functional reach test, 30-second chair-stand test and 6-minute walk test.

		F	p value	η²_p
Body mass index	Time	2.0	0.135	0.13
	Group	1.0	0.368	0.05
	Time × group	1.3	0.274	0.09
Timed-up and go	Time	6.6	0.001	0.30
	Group	3.5	0.036	0.13
	Time × group	21.1	<0.001	0.58
Functional reach	Time	3.7	0.018	0.21
	Group	1.1	0.330	0.05
	Time × group	5.9	0.002	0.29
30–second chair stand	Time	2.6	0.065	0.15
	Group	9.5	<0.001	0.29
	Time × group	6.9	0.001	0.31
6-minute walk test	Time	4.1	0.011	0.20
	Group	3.3	0.045	0.11
	Time × group	10.0	<0.001	0.37

η²_p: partial eta squared.

The BMI changes correlated with the 6-minute walk test changes (r = –0.20, p = 0.003). The Timed Up and Go Test changes correlated with changes in the 30-second chair stand test (r = –0.52, p < 0.001) and 6-minute walk test (r = –0.55, p < 0.001). The functional reach test changes correlated with changes in 6-minute walk test (r = 0.18, p = 0.010) and Timed Up and Go Test (r = –0.24, p < 0.001). There was also a correlation between the 30-second chair stand test and the 6-minute walk test performance (r = 0.46, p < 0.001).

In 1-RM leg press, leg extension and leg curl percentage gains, repeated measures ANOVA showed significant differences between baseline and Week 8, Week 16, Week 24 and Week 32 (p < 0.001 and η²_p > 0.750 for all) in the combined exercise group.

Adverse events

None of the participants in the exercise groups reported musculoskeletal injuries during the study period. During the intervention, there were three fall incidents. One in the aerobic exercise group during a walk inside the facilities on a rainy day where the participant slipped without any physical consequences; two in the combined exercise group during different resistance training sessions, including one immediately after the arm curl exercise where the participant temporarily lost his consciousness owing to postural orthostatic hypotension and fell helpless on the ground (fortunately there were no physical injuries); the other was immediately after the lateral pull-down exercise with the participant still seated, but this time the instructor was able to prevent the fall. Since the last two were with the same participant, he was forwarded to cardiology and for a tilt-table test. There were no contraindications to the practice of physical exercise.

Discussion

The main finding of the present randomized controlled trial was that combined aerobic and resistance exercise, compared with aerobic exercise stand-alone, was more effective in improving fall risk factors such as balance, postural control, mobility and leg strength. Our results add evidence to the beneficial effect of exercise as a strategy to improve fall risk factors, and further highlight the long-term benefits of combining resistance and aerobic exercise modes.

The Timed Up and Go Test evaluates agility, static and dynamic balance in tasks as standing, walking, turning and sitting, but it is highly dependent on the mechanical power developed by the lower limbs.^19,21 At baseline, there were no between-group differences on the Timed Up and Go Test, but a significant time × group interaction was observed after 32 weeks of exercise (p < 0.001), with almost 60% of variation accounted for by the exercise mode, which represents a large effect (η²_p = 0.58, see Table 2). This means that the differences in performance between the combined exercise group and the other groups significantly increased over time. The aerobic exercise group decreased the Timed Up and Go Test performance from 7.7 to 7.0 seconds (–9.1%), but the combined exercise group decreased from 7.4 to 5.9 seconds (–20.3%). These results suggest that the combined exercise program was more effective in increasing agility, static and dynamic balance, but also leg strength and power.

The increasing leg strength was controlled by the 30-second chair stand test, and both experimental groups improved their performance (see Table 1). However, the magnitude of the improvements was different; the aerobic exercise group increased 7.3%, while the combined exercise group increased 20.8%. Indeed, the time × group interaction was significant (p = 0.001), with 31% of the variation accounted for by the exercise mode (η²_p = 0.31, see Table 2). These results were expected, because in the resistance training sessions participants had to perform leg press, leg curl and leg extension, and these leg exercises induced maximum strength gains measured by the 1-RM tests. Other studies have shown that maximum strength gains in lower limbs induces significant improvements in the performance of the Timed Up and Go Test.^15,23 Furthermore, we found significant relationship between the increasing 30-second chair stand test repetitions and the decreasing Timed Up and Go Test seconds (r = –0.52, p < 0.001).

The Timed Up and Go Test performance is also highly correlated with walking speed.¹⁵ Both experimental groups increased walking speed, controlled by the 6-minute walk test performance (see Table 1). However, a significant time × group interaction was identified (p < 0.001), with almost 40% of variation accounted by the exercise mode (η²_p = 0.37, see Table 2). Furthermore, we found a significant relationship between increased distance covered on the 6-minute walk test and the decreased time on the Timed Up and Go Test (r = –0.55, p < 0.001). The 6-minute walk test aims to assess aerobic endurance in older adults, which is dependent on cardiovascular function, but also reflects the role of lower limb power and strength in the energy cost of walking.²⁴ Therefore, one possible explanation for relevant performance increment in the combined exercise group compared with the aerobic exercise group (+10.9% vs. +3.5%) can be partly attributed to increased walking economy, as a function of peripheral adaptations of which strength and power of the lower limbs improvements are functional indicators.^24,25 Also, the significant relationship founded between the 6-minute walk distance and the lowest BMI (r = –0.20, p = 0.003) explains, partially, the increased walking economy theory, since excess of body weight increase the energy cost of walking in older adults.²⁶

In addition, a significant time × group interaction was observed in the functional reach test performance (p = 0.002), with almost 30% of the variation accounted for by the exercise mode (η²_p = 0.29, see Table 2). Indeed, both exercise groups increased their performance compared with baseline, but the improvements observed over time were significantly higher in the combined exercise group (27.5% vs. 10.9%). These improvements coincided with dynamic balance and walking speed improvements, since we found a significant relation between the functional reach test improvements and the Timed Up and Go Test decreased seconds (r = –0.24, p < 0.001), and the 6-minute walk test distance (r = 0.18, p = 0.010). Collectively, the results suggests that the combined exercise group improved postural control, and static and dynamic balance, which were already identified as independent fall risk factors.^1,3

Although the participants in this study were healthy and presented good performance in all tests at baseline, overall we can assume that the participants who practiced combined aerobic and resistance exercise for 32 weeks improved fall risk factors, which could result in augmented protection for falls. In contrast, the control group remains similar to baseline or even worse, suggesting an increased risk.

This study had several strengths. This randomized controlled trial was well conducted in the community, with long-term follow-up, and five repeated measures. The post-hoc power analysis estimated using G-Power 3 was high (1-β = 0.99).²⁷ Exercise intensity was regularly controlled; the mean training adherence was high (85% for the aerobic exercise group and 88% for the combined exercise group); and adverse events were few.

Despite the solid results, the study also had some limitations. The study was single blinded; and therefore the intervention delivery instructors were not blind to the group assignment. This was minimized by the fact of the evaluators being blind to the participant’s allocation. The study consisted only of men who lived at home independently, without limitations to exercise and no history of falls. Finally, it should be highlighted that the current study does not directly measure the risk of falling, as well as the fear of falling and/or fall episodes outside the programs. Therefore, caution in the generalization of results to women or population with a history of falls or specific pathologies or diseases, has to be observed.

In conclusion, combining resistance and aerobic exercise is more effective for the improvement of fall risk factors than aerobic exercise alone in old-aged men. However, independently of regimes, exercise compared with no exercise is advantageous in the improvement of fall risk factors.

Clinical message

Exercise training mitigates the age-related reduction in functional capacity, which is associated with the fall risk.

Exercise interventions to improve functional capacity should combine resistance and aerobic exercises.

Combined exercise training results in greater improvements of postural control, balance and walking performance.

Footnotes

Contributors

NS and JO: conception and design of the experiment. NS, AS and RM: data collection. All authors: analysis and interpretation of data; drafting or revising the manuscript for intellectual content; approval of the final version of the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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