Reducing Risk of Falling in Older People Discharged From Hospital: A Randomized Controlled Trial Comparing Seated Exercises, Weight-Bearing Exercises, and Social Visits

Article Outline

• Abstract
• Methods
  • Subjects and Recruitment
  • Interventions
    • Seated exercises
    • Weight-bearing exercises
    • Social visit group
    • Safety while exercising
  • Outcome Measures
  • Statistical Analysis
• Results
  • Baseline Data, Completion Rates Compliance, and Intervention Intensity
  • Primary Outcome Measures
  • Secondary Outcome Measures
  • Adverse Events
  • Those Who Fall
• Discussion
  • Study Limitations
• Conclusions
• Acknowledgments
• References
• Copyright

Abstract 

Vogler CM, Sherrington C, Ogle SJ, Lord SR. Reducing risk of falling in older people discharged from hospital: a randomized controlled trial comparing seated exercises, weight-bearing exercises, and social visits.

Objective

To compare the efficacy of seated exercises and weight-bearing (WB) exercises with social visits on fall risk factors in older people recently discharged from hospital.

Design

Twelve-week randomized, controlled trial.

Setting

Home-based exercises.

Participants

Subjects (N=180) aged 65 and older, recently discharged from hospital.

Interventions

Seated exercises (n=60), WB exercises (n=60), and social visits (n=60).

Main Outcome Measures

Primary outcome factors were Physiological Profile Assessment (PPA) fall risk score, and balance while standing (Coordinated Stability and Maximal Balance Range tests). Secondary outcomes included the component parts of the PPA and other physical and psychosocial measures.

Results

Subjects were tested at baseline and at completion of the intervention period. After 12 weeks of interventions, subjects in the WB exercise group had significantly better performance than the social visit group on the following: PPA score (P=.048), Coordinated Stability (P<.001), Maximal Balance Range (P=.019); body sway on floor with eyes closed (P=.017); and finger-press reaction time (P=.007) tests. The seated exercise group performed better than the social visit group in PPA score (P=.019) but for no other outcome factor. The seated exercise group had the highest rate of musculoskeletal soreness.

Conclusions

In older people recently discharged from the hospital, both exercise programs reduced fall risk score in older people. The WB exercises led to additional beneficial impacts for controlled leaning, reaction time, and caused less musculoskeletal soreness than the seated exercises.

Key Words: Accidental falls, Exercise therapy, Muscle weakness, Rehabilitation

List of Abbreviations: ADLs, activities of daily living, CG, control group, CI, confidence interval, PPA, Physiological Profile Assessment, SR, seated progressive resistance training, WB, weight bearing

PEOPLE RECENTLY DISCHARGED from hospital are at increased risk of falls and readmission to hospital.¹, ² The increased fall risk associated with medical problems¹ is likely exacerbated by acute illness and relative inactivity while in hospital.

However, in the only adequately powered study of exercise for prevention of falls in people after discharge from hospital, Latham et al³ found no benefits from seated resistance exercises on muscle strength or fall rates. This exercise regimen was difficult to progress and caused a high rate of musculoskeletal injury. Similar studies have also found that some strengthening programs do not improve lower-limb strength.⁴, ⁵

Recent studies have designed and evaluated strengthening programs that involve the addition of resistance to exercises performed in WB positions (ie, standing, walking) that mimic daily activities.⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹ These programs have been shown to have a greater effect on daily task performance (ie, sit-to-stand)¹¹ than seated strengthening exercises. However, such exercises may be more difficult to perform in an unsupervised home program.

With these issues in mind, we developed an exercise program aimed at improving strength and balance that could be conducted in WB positions.

We conducted a randomized controlled trial to compare the effects of this WB program, seated strengthening exercises, and a no-exercise social visits program on risk factors for falls and musculoskeletal soreness.

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Methods 

Subjects and Recruitment 

Inpatients from Aged Care and Rehabilitation, General Medicine and Orthopaedics Services, Royal North Shore and Hornsby Ku-ring-gai Hospitals, northern Sydney, Australia, were screened for eligibility by a geriatrician (C.M.V.) and approached regarding participation after leaving hospital. Eligible subjects were 65 years or older. Subjects were excluded if they had medical contraindications to exercise,¹², ¹³ if they were cognitively impaired (Mini-Mental State Examination score <24 out of 30¹⁴), or if they were to be discharged to a high-care residential facility for the aged. Three hundred eleven subjects were eligible and provided written informed consent.

Baseline assessments were conducted after subjects had returned home, were medically fit to exercise, and had completed hospital-related rehabilitation (within 3 months of discharge). One hundred eighty subjects completed the baseline assessments and were then randomized to 1 of 3 groups: SR, WB exercises, and the CG (frequency-matched social visits) (fig 1).

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• Fig 1. 

  Subject flow through the study.

Randomization (independent of baseline assessment results) was performed in blocks of 15 subjects by computer-generated random numbers. Group allocations for each subject were concealed in opaque envelopes. The outcome assessor remained unaware of group allocation. Ethical approval was obtained from the local health service human research ethics committee.

Interventions 

Three experienced physical therapists delivered the interventions to subjects at their homes or at a low-level aged-care facility. The physical therapist visited 8 times in 12 weeks to individually prescribe and ensure correct performance of each exercise, and to progress the exercises when the subject was capable. Subjects were asked to exercise 3 times a week.

This group was prescribed exercises to be performed while sitting on a standard dining room chair. Exercises targeted hip flexion, extension, abduction, knee flexion and extension, and ankle plantar- and dorsiflexion. An increasing amount of resistance from cuff weights and exercise bands was added to the exercises with the aim of a 10 to 12 repetition maximum load (ie, the weight that could only be lifted 10–12 times). Weights began at 0.5kg and were progressed according to participant capability in 0.5kg increments.

Subjects assigned to this group were prescribed exercises to be performed while standing, with a chair or bench for support if required. Lower-limb strength was targeted with exercises such as heel raises, partial squats, sit-to-stand, and stepping forward and sideways up onto blocks. Resistance was provided with weight-loaded waist belts, aiming for a 10 to 12 repetition maximum load. Additional exercises aimed to enhance WB task performance and included: reaching and leaning in standing, tapping one foot onto and off a block, controlled anteroposterior weight shifts and controlled pelvic hitches, tandem standing and walking, and getting up off the floor.¹⁵ If a participant was judged to be unable to complete all of the exercises, priority was given to the exercises that primarily targeted strength. (More details of the exercises are available from the authors on request.)

Subjects randomized to the social visit group were visited with the same frequency as the exercise group subjects by a research assistant. The 1-hour visits consisted of playing board games or cards, and general conversation. No exercises or walking were done during these visits.

Subjects received written instructions with illustrations of the exercises and safety information. Participants randomized to SR were instructed on safe ways to set up equipment, lift weights, and maintain a correct posture while exercising, to minimize injury. Those in the WB group were given similar instructions to the seated group, as well as being strictly advised to perform all standing exercises next to a solid surface such as a kitchen bench or chair/table. Exercises for both groups were not progressed unless they were being done safely.

Outcome Measures 

Fall risk factors were measured at baseline and at the end of the 12-week trial. The primary outcome measures were the PPA composite fall risk score¹⁶ and tests of the ability to lean while standing (the Coordinated Stability test and Maximal Balance Range¹⁷, ¹⁸).

The PPA composite score was chosen because it can predict older people at risk of falling with 75% sensitivity and specificity in community settings¹⁸ and it contains components that are quantitative, reliable, and responsive to change with exercise.¹⁶ The composite score is calculated by summing standardized canonical correlation coefficients for 5 tests from the PPA short form. These tests were identified from discriminant function analysis as the best set of independent predictors of status as someone who falls.¹⁶ Test-retest reliability (intraclass correlation coeffiecient_3.1) of the PPA composite score, as determined in a study of 31 older people tested on 2 occasions 2 weeks apart,¹⁹ was .71 (95% CI, .48–.85).

Visual contrast sensitivity was assessed by the Melbourne Edge Test.²⁰, ²¹ Quadriceps strength was measured isometrically in the stronger leg, with the angles of the hip and knee at 90° with subjects seated. Simple reaction time was measured with a light as the stimulus and a finger press as the response. Postural sway was measured with a swaymeter (a 40cm rod attached to the waist) that measured displacements of the body on millimeter graph paper. Total sway (number of square millimeter squares traversed by the pen) was recorded. The sway test was performed with subjects standing on a foam rubber mat (60cm×70cm×15cm thick) with eyes open. The fifth measure of the standard PPA, lower-limb proprioception, was not assessed because it was considered that this measure would not be responsive to change with exercise and because the test is relatively difficult to administer in subjects' homes. To calculate the PPA total score, a community mean result for proprioception was applied for all subjects.

The Maximal Balance Range and Coordinated Stability have been shown to be predictors of falls.²², ²³, ²⁴ The Maximal Balance Range (reliability coefficient=.74; 95% CI, .56–.86¹⁷) measures the maximal forward- and backward-leaning capacity of the participant. Subjects were asked to lean forward as far as possible from the ankles without moving the feet, then back as far as possible. Maximal anterior-posterior distance moved was measured with the swaymeter, which extended in the anterior plane. The subjects had 3 attempts at the test, with the best trial taken as the test result.

The Coordinated Stability test (reliability coefficient=.83; 95% CI, .70–.91¹⁷) measures subjects' ability to adjust balance in a steady and coordinated manner while placing them near or at the limits of their base of support. In this test, the swaymeter was again attached to the waist with the rod extending anteriorly. The subject was asked to adjust balance by bending or rotating the body without moving the feet so that the pen on the end of the rod followed and remained within a convoluted track that was marked on a piece of paper attached to the top of an adjustable-height table. To complete the test without errors, subjects had to remain within the track, which was 1.5cm wide, and be capable of adjusting the position of the pen 29cm laterally and 18cm in the anterior-posterior plane. A total error score was calculated by summing the number of occasions the pen on the swaymeter failed to stay within the path. Subjects attempted the test twice, with the better trial taken as the test result.

Secondary outcome measures assessed other aspects of sensorimotor function, balance, mobility, depression, quality of life, and falls self-efficacy. The tests were foot-press reaction time, body sway (on the floor with eyes open and closed, and on foam with eyes closed), walking speed, tandem and semitandem stance performance, the Hill Step Test,²⁵ the Physical Performance and Mobility Examination (a global test of transfers, walking, balance, and stepping onto steps), and the ability to rise from the floor (quantified as the number of steps completed [maximum 7] to rise from the floor in a backward-chain method described by Reece and Simpson¹⁵). Self-reported ADLs abilities was assessed with the Lawton-Brody ADLs questionnaire.²⁶ Depression was assessed with the Geriatric Depression Scale,²⁷ quality of life was assessed with the Euroqol Scale,²⁸ and falls efficacy was assessed with the Modified Falls Efficacy Scale.²⁹ The Canadian Study of Health and Aging Frailty Scale³⁰ (a 7-point scale that uses clinical judgments to identify frailty) was used to describe the population at baseline.

Adverse events were defined as any injury or symptom resulting from the trial (exercises or assessment) that restricted physical activity or ADLs for more than 48 hours or required medical attention.³ These were classified as cardiovascular, other medical, or musculoskeletal events. Delayed-onset muscle soreness was classified as a musculoskeletal event if it was severe enough to limit ADLs performance.

Falls were also recorded during the 12-week period (via a weekly fall incidence questionnaire) to assess for adverse outcomes. The study was not powered to determine whether the interventions could reduce fall frequency.

Statistical Analysis 

Postintervention between-group differences were analyzed by analysis of covariance with baseline values as the covariate for variables with normal distributions (either raw scores or following logarithmic or squared transformations). If it proved impossible to normalize variable distributions with transformations, change scores were used in the analysis of variance models.³¹ Contrast analyses were undertaken to compare 12-week assessment scores between each pair of groups. The least significant difference procedure for multiple comparisons was used to assess the statistical significance of these comparisons. Adverse events were examined by chi-square analysis. All analyses used 2-sided tests and were by intention to treat, and P values of .05 or less were considered statistically significant. The data were analyzed with SPSS for Windows (version 15.0.1).^a

We used results from our previous studies to estimate that a sample size of 180 subjects (60 per group) was required to provide a power of 90% and a 5% type I error rate (2-sided test) to detect clinically significant (10%–20%) between-group differences in the primary outcome measures. For example, to detect a 15% between-group difference for PPA Composite Score (score .33) with an SD of .80 (from previous trials³²), assuming 10% dropouts and .80 correlation between baseline and follow-up scores, 53 subjects per group would be required.

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Results 

Baseline Data, Completion Rates Compliance, and Intervention Intensity 

The mean age of the 180 study participants was 80±7 years (range, 65–95y), and 143 subjects (79%) were women. Table 1 provides a summary of the baseline demographics of the study population. Table 2 describes the range of diagnoses at hospital admission and corresponding lengths of stay.

Table 1. Demographic and Health Measures at Baseline

Characteristics	Seated Exercise (n=60)	WB Exercise (n=60)	Social Visits (n=60)
Age (y)	80.3±6.6	79.6±7.2	80.0±7.1
No. of medications	6±3	6±3	6±3
Hospital length of stay (d)⁎	11.9±7.6	12.4±11.4	12.6±12.4
Mini-Mental State Examination score (/30)	28±2	28±2	28±2
CSHA Clinical Frailty Scale (/7)†	4±1	4±1	4±1
Women	43(72)	50(83)	50(83)
≥1 fall in previous 12 months	41(68)	40(67)	45(75)
Medications
Using any psychotropic	23(38)	21(35)	22(37)
Using benzodiazepines	16(27)	14(23)	18(30)
Accommodation
Alone in community‡	29(48)	22(37)	27(45)
With family‡	20(33)	27(45)	24(40)
Retirement village‡	9(15)	8(13)	7(12)
Hostel‡	2(3)	3(5)	2(3)
Walking without aids
Indoors‡	45(75)	44(73)	48(80)
Outdoors‡	32(53)	33(55)	37(62)
Number of comorbidities
≤3	20(33)	23(38)	16(27)
4–6	34(57)	33(55)	41(68)
≥7	6(10)	4(7)	3(5)

NOTE. Values are mean ± SD or n (%).

Abbreviation: CSHA, Canadian Study of Health and Aging.

Table 2. Length of Stay and Principal Diagnosis for Hospitalization of Participants

When comparing the baseline results of the current study with those from the Randwick Falls and Fractures Study¹⁷, ¹⁸, ³³ (a study of community-dwelling older women randomly recruited via electoral rolls in Sydney, Australia), in the current study, subjects had impaired performance in all the primary outcome measures, indicating that those recently discharged from hospital are older and more impaired than the general community population of older people.

There were no marked differences between the 3 groups at baseline (see table 1). At the end of the 12-week intervention period of the trial, 9 participants had withdrawn from the study (3 from each group) (see fig 1). Two deaths occurred, both unrelated to the exercise programs. These figures represent a dropout rate of 5%.

There was no statistical difference in completion of exercise sessions between the SR group and WB group (P=.236). On average, SR subjects completed 70% of the 36 recommended exercise sessions, and WB subjects completed 62% of the recommended sessions. SR subjects were prescribed an average of 6.8 (range, 5–7) different exercises during the study period, and subjects in the WB group were prescribed an average of 11.3 exercises (range, 5–15). By the end of the study period, SR subjects were using an average of 2kg (range, 0–4kg) for the seated knee extension exercises and exercise bands with a 6kg average end resistance for the hip extension exercises (range, 2.7–6.9kg). Subjects in the WB group were using an average of 1.4kg to resist the knee bends and heel raises (range, 0–3.6kg).

Primary Outcome Measures 

There was a significant between-group difference at retest in the PPA fall risk score at the end of the intervention period, and contrast analysis showed that both the SR group and WB group performed significantly better than the CG (table 3).

Table 3. Baseline–12 Week Comparisons of Primary Outcome Measures

Outcome Variables	Seated Exercise	n	WB Exercise	n	Social Visits	n	Between-Group Analysis P	Indicator of Improvement
PPA composite score							.042⁎	Score decrease
Baseline	1.19±1.22	60	1.29±1.27	60	1.37±1.33	60
12 weeks	0.99±1.30	57	1.11±1.38	57	1.44±1.32	57
Maximal balance range (mm)							.044†	Score increase
Baseline	115±43	60	122±48	60	112±45	60
12 weeks	126±48	57	145±49	54	120±51	57
Coordinated stability (error score)‡							<.001§	Score decrease
Baseline	18.3±12.2	60	18.9±13.7	60	18.4±12.8	60
12 weeks	13.6±11.6	57	10.8±12.5	55	16.4±12.0	56

NOTE. Values are mean ± SD or as otherwise indicated.

There were also significant between-group differences for the leaning balance measures of Coordinated Stability and Maximal Balance Range. For Coordinated Stability, contrast analysis identified significant improvements in performance for the WB group compared with both the SR group and the CG. The Maximal Balance Range contrast analysis similarly identified significant improvements between the WB group and the CG (see table 3).

Secondary Outcome Measures 

There were significant between-group differences for sway on the floor with eyes closed and finger-press reaction time. Contrast analysis revealed better performance in the WB group compared with the CG for both tests (table 4).

Table 4. Baseline–12-Week Comparisons of Sensorimotor, Balance, and Mobility Measures

Outcome Variable	Seated Exercise	n	WB Exercise	n	Social Visits	n	Between-Group Analysis P	Indicator of Improvement
Quadriceps strength (kg)
Stronger leg							.730	Score increase
Baseline	17.1±7.1	60	16.7±6.0	60	16.6±6.3	60
12 weeks	17.5±7.5	57	16.7±6.7	57	17.3±6.8	57
Weaker leg							.453	Score increase
Baseline	13.1±5.0	60	13.2±4.9	60	13.2±5.9	60
12 weeks	16.1±6.4	57	15.3±6.2	56	15.6±7.1	57
Finger-press reaction time (ms)⁎							.027†	Score decrease
Baseline	264±64	60	291±81	60	290±88	60
12 weeks	263±84	57	273±92	57	290±78	57
Foot-press reaction time (ms)⁎							.151	Score decrease
Baseline	341±68	59	358±106	60	359±81	60
12 weeks	339±82	57	333±93	57	350±69	57
Contrast sensitivity (dB)							.135	Score increase
Baseline	15.7±3.0	60	16.2±2.3	60	16.2±2.5	60
12 weeks	16.4±2.7	57	15.9±2.4	57	16.4±3.0	57
Sway (mm)
Floor eyes open⁎							.473	Score decrease
Baseline	84±42	60	86±79	60	79±45	60
12 weeks	81±47	57	76±61	57	80±43	57
Floor eyes closed⁎							.050‡	Score decrease
Baseline	128±88	60	119±70	60	118±74	60
12 weeks	120±71	57	113±78	57	129±70	57
Foam eyes open§							.391	Score decrease
Baseline	143±72	60	141±91	60	147±84	60
12 weeks	136±79	57	140±95	57	157±91	57
Foam eyes closed§							.176	Score decrease
Baseline	290±139	60	271±140	60	307±137	60
12 weeks	270±140	57	292±148	57	309±133	57
6-m walk velocity, fast pace (m/s)							.960	Score increase
Baseline	0.8±0.2	60	0.8±0.3	60	0.8±0.3	60
12 weeks	0.9±0.3	57	0.9±0.3	56	0.9±0.4	57
Hill Step Test (steps/15s)
Stronger leg							.708	Score increase
Baseline	9±5	60	9±5	60	9±5	60
12 weeks	11±6	57	11±6	54	10±5	56
Weaker leg							.714	Score increase
Baseline	10±5	60	9±5	60	9±5	60
12 weeks	11±5	57	11±6	54	10±5	56
PPME/12§							.401	Score increase
Baseline	10±2	60	10±2	60	9±3	60
12 weeks	10±2	57	10±3	57	10±3	57
Semitandem stance (s)∥							.136	Score increase
Baseline	30 (4–30)	60	30 (4–30)	60	30 (9–30)	60
12 weeks	30 (26–30)	57	30 (12–30)	54	30 (4–30)	58
Tandem stance (s)∥							.083	Score increase
Baseline	9 (2–30)	60	11 (2–30)	60	9 (2–30)	60
12 weeks	19 (4–30)	57	30 (3–30)	54	8 (2–30)	58
Getting off floor (score/7)∥								Score increase
Baseline	0 (0–6)	37	0 (0–0)	36	0 (0–4)	38
12 weeks	0 (0–7)	36	0 (0–3)	34	0 (0–6)	38

Abbreviation: PPME, Physical Performance and Mobility Examination.

There were no between-group differences for the other components of the PPA, although contrast sensitivity would not be expected to change as a result of an exercise intervention (see table 4).

There were no other statistically significant between-group differences for any of the other secondary physical outcome measures at the end of the intervention (see table 4), nor for psychosocial measures.

Adverse Events 

There were no cardiac or other medical adverse events in any group. All adverse events were musculoskeletal; there were a total of 22 events reported (in 22 people). Soreness (lower back, hip, knee pain) was the most common and occurred more frequently in those with preexisting arthritic or musculoskeletal conditions. There was a significant difference in the rate of adverse events between the 3 groups (χ²=9.43, df=2, P=.009). Thirteen people (22%) in the SR group experienced an adverse event (number needed to harm=5; 95% CI, 3–15), compared with 7 (12%) in the WB group (number needed to harm=12; 95% CI, –61 to 5) and 2 (3%) in the CG.

Those Who Fall 

There was no significant difference (χ²=1.47, df=2, P=.48) between the groups in the proportion of those who fall (7 from SR group, 12 from the WB group, and 10 from the CG) during the 12-week trial period. One WB subject fell while carrying out the program exercises.

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Discussion 

In this population of older people recently discharged from hospital, both SR and WB exercises greatly lowered the risk of falling, as indicated by reductions in PPA composite scores. The WB exercise intervention, however, showed additional benefits over SR in that it produced fewer musculoskeletal adverse advents and provided improvements in leaning balance measures that may afford additional protection against falling in this at-risk group.

PPA fall risk is designated mild if the score is between 0 and 1, moderate between 1 and 2, and marked between 2 and 3.¹⁶ The average score at baseline was 1.28 for exercise groups, placing the population in the moderate fall risk group.

Of the 4 components that contribute to the calculation of the fall risk score in this study, we hypothesized that postural sway, quadriceps strength, and hand reaction time would be amenable to change by the exercise programs. Examination of the PPA components indicates that the reductions in fall risk scores were primarily mediated by small improvements in reaction time, and maintained postural sway in the WB group and small decreases in sway in the SR group. Previous studies have found that WB exercises can improve both postural sway and reaction time.³³, ³⁴ The lack of an improvement in sway in our WB group may reflect insufficient intensity of the program. The finding that SR improved postural stability contrasts with some previous studies,³⁵, ³⁶ but it is consistent with a recent study conducted in older women with osteoporosis.³²

Quadriceps strength was not improved by either exercise program. This has been found in other studies of exercise in older people.³, ⁴, ⁵, ³⁷, ³⁸ Our intervention was delivered by experienced physical therapists who carefully prescribed the amount of resistance to aim for a 10 to 12 repetition maximum load (ie, the recommended intensity to improve strength following the American College of Sports Medicine guidelines³⁹). However, we found that the resistance used by participants was relatively low and progression of weights was difficult. This probably contributed to the lack of an effect on muscle strength. Although there are many benefits of strength training for older people,⁴⁰, ⁴¹ it seems difficult to deliver programs at a sufficient yet safe intensity in a home setting in this population.

There were more adverse events in the SR group than the WB group, despite careful attention to technique, and this finding replicates those of Latham et al.³ Given that seated resistance exercises are not physiologic movements when compared with the WB exercises, there may be added wear on knee, hip, and back joints when weights are added, particularly in a frailer group of older people with comorbidities. We suggest that future studies continue to document adverse events in a consistent, predefined manner so benefits and risk of these exercises can be rigorously compared. The number needed to harm for the SR group was 5 (95% CI, 3–15), a statistically significant result, compared with the nonsignificant value of 12 (95% CI, −61 to 5) for the WB group. When weighing benefits with harm for the SR group, there is a great potential for musculoskeletal injury after treating only a small number of patients, with no real added improvements in fall risk factors when compared with the WB group (whose adverse event rate did not differ greatly from the CG).

Up to 50% of those who fall are unable to get off the floor after a fall, even when they experience no injury.⁴² Getting up from the floor was chosen as part of the WB exercise program to identify whether practice in this task could improve the participants' ability to perform the task unaided, and perhaps improve fear of falling as a consequence. Neither exercise program greatly improved the ability to get up off the floor, and many participants refused or were unable to practice this task. This is despite the fact that all groups scored the lowest possible median score at baseline and clearly had potential for improvement. This lack of response may correlate with lack of improvement in quadriceps strength. Further research is required to determine the optimal way of teaching this task in frail populations, particularly in those recently discharged from hospital, and may require the inclusion of upper-body strengthening exercises.

The current study has several strengths. Dropout rates for the program were low, and compliance with the interventions was good. The CG also received an attention program of the same intensity to that of the exercise programs to account for the potential effects that socialization might have on the outcome measures in this trial.

Study Limitations 

Our trial has some limitations. Although exclusion criteria were kept to a minimum, it was necessary to exclude people for whom it was considered unsafe to prescribe a home exercise program. This resulted in many people with moderate to severe cognitive impairment, unstable cardiac conditions, and uncontrolled hypertension being excluded from the trial, which limits the generalizability of the study findings. Some participants were excluded as a result of criteria relating to the seated exercise, so the inclusion of the functional WB exercise program alone would have reduced the number of people excluded on medical grounds. A second limitation is that in prescribing the WB group home exercise program, we emphasized safety to minimize the risk of falls while exercising. As a result, participants may not have performed the exercises in as challenging a manner as they may have in a more supervised program, and this may have mitigated maximal benefits. Finally, although participants were asked not to mention their group allocation to the outcome assessor, occasionally participants did reveal their group allocation during follow-up. However, to minimize observer bias, the outcome assessor administered the assessments without reference to baseline results and used standardized scripts and protocols for all tests.

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Conclusions 

Our findings indicate that on the basis of PPA scores, in older people recently discharged from hospital, both seated and WB exercises can reduce the risk of falling. WB exercise, however, appears to provide additional improvements in leaning balance and results in fewer musculoskeletal adverse events.

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Acknowledgments 

We thank Lydia Au, MBBS, and Nihal Nanda, MBBS, who assisted with recruitment at Hornsby Ku-ring-gai Hospital. We also thank the research physical therapists: Susan Murray M. Gerontology, Dip.Remed.Gymnast.Recreat.Ther, Patricia Pamphlett, Dip.Phys, BA, Yoke-feng Woodley, B.Appl.Sci(Physio), Suzanne Herring, B.Appl.Sci(Physio), and Monica Adams, Dip.Phys, BA(Hons), and our research assistants, Marcella Kwan, BSc, MPH, and Anne Tiedemann, PhD.

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