Exercise as it relates to Disease/Does increase in intensity and frequency of physical activity reduce fear of falls in older adults?
The paper is a critique on the article: Ryuichi Sawa, PT, PhD, Tsuyoshi Asai, PT, PhD, Takehiko Doi, PT, PhD, Shogo Misu, PT, PhD, Shunsuke Murata, PT, MS, Rei Ono, PT, MPH, PhD, The Association Between Physical Activity, Including Physical Activity Intensity, and Fear of Falling Differs by Fear Severity in Older Adults Living in the Community, The Journals of Gerontology: Series B, Volume 75, Issue 5, June 2020, Pages 953–960
This is an assignment created for the unit 'Health Disease and Exercise' at the University of Canberra. Semester 2, 2020
What is the background of this research?
Fear of falling (FoF) is a serious issue in elderly. It is often recognized as a lasting concern about falling that can lead an individual to avoid activities that he or she remains capable of performing.  Prevalence of FoF is associated with increasing age and particularly in woman . It has been a critical issue as it affects the quality of life in elderly while decrease in physical functioning. In which it may result in more severe health and life issues such as falls, avoidance of physical activity, increased risks of chronic disease and more. 
FoF needs to be addressed properly. However, studies regarding this matter are usually measured in a direct, single-item, closed-ended question approach which may possibly underestimate the severity of FoF.  Therefore, this cross-sectional study is created to penetrate deeply in this area and provide a more accurate view on this matter. It is performed on a sample of community-dwelling people and aimed to measure whether FoF varies with exercise levels by step count, LPA, MVPA. It is said to be the first study to take account of both FoF severity and physical activity intensity in an older sample that includes both men and women.
Where is the research from?
The research is conducted by Ryuichi Sawa, PT, PhD, Tsuyoshi Asai, PT, PhD, Takehiko Doi, PT, PhD, Shogo Misu, PT, PhD,Shunsuke Murata, PT, MS and Rei Ono, PT, MPH, PhD. They are all experts in the field of global health, physical therapy and rehabilitation in Japan. This study was conducted with behalf of Japan Center for International Exchange, Japan, Department of Community Health Sciences, Kobe University Graduate School of Health Sciences, Japan, Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Japan Department of Preventive Gerontology, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Japan, and Japan Society for the Promotion of Science, Japan.
What kind of research is it?
It is a cross-sectional, questionnaire-based observational study held at a local community association center with 242 elderlies living independently in the community (mean age: 75.1 ± 5.4 years). FoF was defined using the Falls Efficacy Scale International and categorized into three levels (low, moderate, and high). The study is aimed to explore the relationship between Fear of falls, step count and physical activity level in the population.
The sample size is relatively small to previous questionnaire-based studies. It may affect its credibility as it increases the margin of error and variability. Which makes the result may not be significant through the population.
What did the research involved?
Sociodemographic characteristics (such as age, sex, height, weight, fall history, pain site, etc.) were collected using a self-reported questionnaire and compared in regards to the Guideline for the Prevention of Falls in Older Persons. Participants will then be categorized into three groups (low, moderate, high) based on their falling history and in accordance to FES-I scale. 
Then they were instructed to attach a uniaxial accelerometer to their hip for seven consecutive days, following their initial examination. The device must be worn anytime during the trial, except for bathing and swimming. A valid wearing day should consist of at least 8 hours of valid wear time, which a valid hour defined as no more than 10 consecutive minutes of zero-activity intensity. Data with a minimum of 5 valid days will be included. They will be collected after 7 days to calculate step count and metabolic equivalent values between groups.
Strength of the study
- The trend between FoF and physical activity levels with intensity is well described and shown in the study.
- Different variables were categorized and set to minimize biased distribution.
Weakness of the study
- Participants were reported well-functioning elderly, while this limit the comprehensiveness of the findings.
- All the data in this study is through multiple self-report questionnaires and scales. Accuracy of the data is in doubt, whereas previously large population-based studies have reported self-reported physical activity levels were higher compared to accelerometer-base controlled data. While whether fall-related self-efficacy may access FoF or not is still controversial.
What were the basic results?
|Physical activity, median (IQR)||Total||Fear of fall (FoF)|
|Step count(steps/day)||7997 (5,691,10,510)||9016 (6866,11869)||8156 (6194,10476)||6149 (3926,8546)|
|LPA(min/day)||62.1 (44.6,86.2)||70.4 (49.5,104.4)||62.1 (49.4,81.8)||49.0(31.0,80.1)|
|MVPA(min/day)||18.4 (10.2,38.5)||24.4 (14.0,48.5)||22.8 (12.4,42.2)||11.6 (3.9,19.7)|
- LPA= Light-intensity physical activity
- MVPA= moderate to vigorous-intensity physical activity
Results shown significant linear associations with FoF groups (step count 95%CI: −4,370 to −1,858; LPA, 95% CI: −34.7 to −11.8; MVPA,95% CI: −24.0 to −7.6). High FoF was significantly associated with a decrease in all measures of physical activity in crude models(step count, 95% CI: −4,370 to −1,858; LPA, 95% CI: −34.7 to−11.8; MVPA, 95% CI: −24.0 to −7.6)
Step count and physical activity intensity showed significant linear trends across a fear of falling severity. High fear of falls decreased with around 2000 steps/day while associated with lower physical activity (both LPA and MVPA) duration. Higher fear of falling level was associated with a decrease in physical activity.
What conclusion can we take from this research?
From the current study, it is found that even in elderly without motor dysfunction, decreased physical activity is expected with an increase in fear of falls severity. Likely, more physically active you are and the more effort you pay, the less fear of fall you encounter. The study did bring out the association between FoF severity and physical activity deviate between groups with different physical intensity levels in the community-dwelling elderlies. However, just like many studies in this field, they are limited to cross-sectional design, it only addresses the association between FoF and physical activity while unable to raise other mental and health factors which may affect FoF. Further studies are needed to investigate other factors affecting FoF and causal relationship between FoF and objective measures of physical activity.
The best cure to solve the fear of falling is to tackle the problem from the inside out. Keeping yourself physically active is a good way to maintain your motor function, while adding some moderate to vigorous exercise such as resistance exercise, balance exercise can help to build up your muscles strength and sense of balance which will greatly reduce the fear of falling and the risk of falls. Mentally, when you are physically active and keeping your body mechanism functioning, your sense of fear will reduce as you have the confidence as you exercise enough. While it is advised to progressively increase your exercise intensity and frequency in order to avoid unnecessary injuries, especially for the elderly whose muscular function kept deceasing as they get older and have a relatively lower training volume. Living within your capabilities and improve over time. It is good to check out some guidelines for physical activities as your reference. 
Related web resources
- Tinetti, M. E., Richman, D., & Powell, L. (1990). Falls efficacy as a measure of fear of falling. Journal of Gerontology, 45, Page: 239-243. doi:10.1093/geronj/45.6.P239
- Scheffer, A. C., Schuurmans, M. J., van Dijk, N., van der Hooft, T.,& de Rooij, S. E. (2008). Fear of falling: Measurement strategy, prevalence, risk factors and consequences among older persons. Age and Ageing, 37, 19–24. doi:10.1093/ageing/afm169/ [Avaliable from: https://academic.oup.com/ageing/article/37/1/19/25345
- Yardley, L., & Smith, H. (2002). A prospective study of the relationship between feared consequences of falling and avoidance of activity in community-living older people. The Gerontologist, 42, 17–23. doi: 10.1093/geront/42.1.17/ [Avaliable from: https://academic.oup.com/gerontologist/article/42/1/17/641500
- Maki, B. E., Holliday, P. J., & Topper, A. K. (1991). Fear of falling and postural performance in the elderly. Journal of Gerontology, 46, M123–M131.doi: 10.1093/geronj/46.4.M123
- The Disadvantages of a Small Sample Size
- Ryuichi Sawa, PT, PhD, Tsuyoshi Asai, PT, PhD, Takehiko Doi, PT, PhD, Shogo Misu, PT, PhD, Shunsuke Murata, PT, MS, Rei Ono, PT, MPH, PhD,(2018) The Association Between Physical Activity, Including Physical Activity Intensity, and Fear of Falling Differs by Fear Severity in Older Adults Living in the Community, The Journals of Gerontology: Series B, Volume 75, Issue 5, June 2020, Pages 953–960
- McMurdo, M. E., Argo, I., Crombie, I. K., Feng, Z., Sniehotta, F.F., Vadiveloo, T.,…Donnan, P. T. (2012). Social, environmental and psychological factors associated with objective physical activity levels in the over 65s. PLoS One, 7, e31878. doi:10.1371/journal.pone.0031878
- Australia's Physical Activity and Sedentary Behaviour Guidelines and the Australian 24-Hour Movement Guidelines
- Physical Activity Guidelines for Americans