Looking for the right balance: consideration of exercise approaches in the menopause transition, healthy ageing and early falls prevention

Abstract The development and implementation of effective and cost-efficient strategies to prevent falls in a rapidly growing ageing population is becoming an urgent challenge worldwide. The falls rate for ageing Australians has not decreased despite volumes of research and implementation of a range of interventions for older adults at risk of falls. Poor balance/reduced postural stability has been identified as one of the main factors contributing to falls in the older person and studies have demonstrated detrimental change in sensori-motor factors in adults over 40 years of age. The problem identified that underpins this research is the inability of current intervention programs to stem the incidence of falls in older people and in particular older women. The evidence shows that the contributing factors for falls start to become significant in women between the ages of 40 and 60 which coincide with the menopause transition. Therefore pre-emptive intervention at this time to reverse or control these changes is suggested by the evidence as being a possible avenue to preventing falls later in life. The series of studies comprising this work investigated the efficacy and long term benefits of a specific balance-strategy training (SBST) program for healthy but less active women during menopause transition compared to other common exercise programs and whether participation leads to adoption of a more active lifestyle. Eighty-four healthy women were admitted to the study and allocated to groups on the basis of their activity level. Fifty sedentary subjects were admitted to a randomized controlled trial. They attended the SBST twice-weekly for 12 weeks and were compared to women who remained sedentary. Assessments made at baseline, 3, 9 and 24 months follow-up included personal demographics, Hormone Replacement Therapy (HRT) medication, activity level, balance measures, somatosensory function, ankle flexibility, lower limb muscle strength and cardiovascular endurance. The SBST group showed significant improvement in balance measures (p< 0.003), tactile acuity (p=0.027), ankle flexibility (p< 0.000), lower limb strength (p < 0.006) compared to sedentary controls immediately after intervention. At follow-up, most improvement had been maintained for the SBST group with continued significant improvement in balance (p<0.05), somato-sensory function (p<0.046) and muscle strength (p < 0.046). Cardiovascular endurance also significantly improved for the SBST group (p=0.000). Concurrently the subjects in the Randomized Controlled Trials (RCT) were compared using the same measurements to the remaining 34 women who exercised at a moderate to high intensity level. At 24 months the SBST groups had attained the same cardiovascular endurance level as the exercise control group. When compared to baseline, women in the SBST group showed sustained weight loss (p<0.017) while controls showed a steady weight gain (2.21±3.90 kg) across the 24 months period. In this concurrent study Quality of Life (QoL) was measured using the SF36v2 health survey. Over time there was no overall difference between the groups for QoL using the SF36v2 health survey. Women participating in regular moderately high intensity exercise regimes do not have superior QoL. Immediately after SBST the sedentary group had significant improvement in perceived social function (p< 0.012) and mental health (p<0.043). At 9-months vitality (p<0.03) and 24-months post-intervention mental summary score (p<0.05) improved in sedentary women. SBST participation does improve aspects of QoL. To demonstrate the versatility of the SBST the application was extended to 517 healthy older people aged over 65 was demonstrated in the final clinical study undertaken. A similar outcome regarding reduction of falls risk factors was achieved thereby increasing the applicability of the SBST to a greater population. More successful outcomes have emerged from specific programs that target the multiple systems underpinning balance. It is thus argued throughout the thesis that intervention programs need to be comprehensive and include challenges to the sensory systems and the integration and use of sensory information as well as target elements of the motor control systems such as selective activation and efficient timing of muscle groups, along with flexibility, functional strength and endurance during the execution of exercise based intervention programs. The high prevalence rate of falls documented for women is considered justification for the focus of this research program to explore and develop strategies to improve and/or minimise detrimental changes in balance as women age. This physiotherapist designed and delivered program was certainly shown to be effective in decreasing falls risks across the mid-life and in older decades in order to foster healthier ageing although extrapolation to reduction in falls has not been incorporated. The results of studies such as these may provide evidence of how best to use a multimodal/multi-system approach to pre-emptively address the prevalence of balance problems (as well as other health issues) encountered with ageing. There were some limitations to this study mainly the low subject numbers and omission of follow-up for falls. Future studies including larger numbers should be funded to address these aspects to enable more definite recommendations to be made.