Aging Clinical and Experimental Research Aging Clin Exp Res 19: 300-309, 2007

©2007, Editrice Kurtis

Old women with a recent fall history show improved

muscle strength and function sustained for six months
after finishing training
Nina Beyer1,2, Lene Simonsen3, Jens Bülow3, Tove Lorenzen4, Dorte V. Jensen4, Lone Larsen1,
Ulla Rasmussen1, Michael Rennie5, and Michael Kjær2
1Department of Physical Therapy, 2Institute of Sports Medicine Copenhagen, 3Department of Clinical

Physiology, 4Department of Rheumatology, Copenhagen University Hospital Bispebjerg, Copenhagen

Denmark, 5School of Life Sciences, University of Nottingham, Graduate Entry Medical School, Derby, UK

ABSTRACT. Background and aims: Restricted
physical activity as a consequence of chronic dis-
ease or injury is a predictor of functional decline. The
aim of this study was to test the hypothesis that a 6-
month multidimensional training program would
have sustained beneficial effects upon the physio-
logical, functional and psychological condition of
old women with a recent history of falls. Methods:
Participants were 65 home-dwelling women (70-90
years) identified from hospital records as having had
an accidental fall. After assessment of muscle
strength, balance performance, walking speed, bal-
ance confidence, and physical activity level, the par-
ticipants were randomly assigned to a control group
(n=33) or a training group (n=32), who performed a
multidimensional training program including mod-
erate resistance exercise and balance exercise twice
weekly for 6 months. Measurements were repeated af-
ter 6 and 12 months. Results: Six months of multi-
dimensional training resulted in significant im-
provements and between-group differences in iso-
metric knee extension strength (p<0.05), trunk ex-
tension/flexion strength (p<0.001), habitual/maxi-
mal walking speed (p<0.001) and balance perfor-
mance (p<0.001). At follow-up, 6 months after in-
tervention, these improvements were preserved in
the training group and there was also a significant be-
tween-group difference with regard to balance con-
fidence. No between-group differences were found
concerning number of falls or physical activity level
during the one-year study period. Conclusions: A
multi-dimensional training program produced sig-
nificant improvements in physiological and func-
tional risk factors for falls and disability in women
aged 70-90 years with a recent history of falls.
(Aging Clin Exp Res 2007; 19: 300-309)
©2007, Editrice Kurtis
INTRODUCTION
Physical disability is a major adverse health outcome as-
sociated with aging. Among the important risk factors for
disability there are disease (1), sarcopenia and associated
weak muscles (2-5), decreased walking speed (6, 7), de-
creased balance (5-7), physical inactivity (8), previous
falls (9), and fear of falling (10). The latter is more preva-
lent in people who have already fallen (11) and predicts
further restriction in physical activity (12). Disability in late
life is usually initiated by chronic disease or injury, and re-
striction in physical activity related to this is a predictor of
functional decline (13). Moreover, older people with mo-
bility impairment are at particularly high risk of becoming
disabled (1), which is further augmented if they are phys-
ically inactive (8).
Given these facts, it seems sensible to prevent or delay
the decline in physical capacity and the potential onset of
disability subsequent upon an accidental fall. Studies
have targeted prevention of future falls in patients first
treated in accident and emergency clinics (14), but none
have focused on exercise.
Current information on prevention of falls and further dis-
ability suggest that exercise to improve muscle strength and
balance is important (15, 16). Studies have shown that re-
sistance exercise improves muscle strength in all older
people, across a spectrum from the healthy to those with
co-morbidities (17), extreme old age and frailty (2). In old-
er people with a variety of co-morbidities living at home,

Key words: Accidental falls, exercise, female, risk factors.

Correspondence: Nina Beyer, PT, PhD, Department of Physical Therapy, Institute of Sports Medicine Copenhagen, Copenhagen University
Hospital Bispebjerg, Bispebjerg Bakke 23, DK-2400 Copenhagen NV, Denmark.
E-mail: nb01@bbh.regionh.dk
Received June 11, 2006; accepted in revised form September 14, 2006.

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Aging Clin Exp Res 19: 300-309, 2007 Improved strength and function after training in vulnerable old women
©2007, Editrice Kurtis
moderate to heavy resistance exercise alone have led to im-
provements in function, including walking ability and stair
climbing capacity (17, 18), whereas this is not always the
case in healthy older people (19). These findings may be ex-
plained by a plateau effect in a curvilinear association be-
tween muscle strength and function (20), indicating that re-
sistance exercise must be combined with functional training
in fairly healthy elderly people if improvements in both
strength and function are to be achieved.
The effect of exercise programs with balance exercise
(15) and light resistance exercise in home-dwelling older
people including those at risk of falling (21) have been in-
vestigated. To the authors’ knowledge, no studies have in-
vestigated the effect of a multidimensional training pro-
gram (22) including moderate resistance exercise and
balance exercise on muscle function, physical perfor-
mance and balance confidence in older women with a re-
cent fall history.
The purpose of this study was to test two hypotheses:
1) that 6 months of multidimensional training two days a
week would improve physiological, functional and psy-
chological risk factors for disability in independent home-
dwelling older women with a recent fall history; 2) that
there would be observable benefits of effect of training 6
months later.
METHODS
Inclusion criteria: home-dwelling women aged 70–90
years, who had suffered a fall that consequently required
attention in an emergency room but not hospitalization.
The women should be able to come to the training facil-
ity (no transport provided).
Exclusion criteria: Fractures of the lower extremities
within the last six months, neurological diseases, inability to
understand Danish, and cognitive impairment, i.e., a score
on the Mini-Mental State Examination of less than 24.
Potentially eligible participants were identified from hos-
pital records in the emergency room. Within two weeks
of the accident, these women were contacted by phone,
and those who wanted to participate in the study were
subsequently included during a home visit. Informed con-
sent was obtained according to the Helsinki 2 declaration.
The study protocol was approved by the Ethics Com-
mittee for Medical Research in Copenhagen.
On inclusion, the participants had a general medical ex-
amination to ensure that training was appropriate and
safe. In addition, peak oxygen uptake (VO2peak) was de-
termined on a cycle ergometer (Ergometrics ER 900 L; Er-
goline, Bitz, Germany) during a graded exercise test, with
simultaneous recording of the ECG to evaluate the likeli-
hood of cardiovascular complications during training. Oxy-
gen uptake and carbon dioxide output were measured
continuously on an Oxycon Champion System (Jaeger,
Wuerzburg, Germany) using a facemask and the breath-by-
breath technique, and ECG was recorded continuously
(Athena; Simonsen & Weel, Albertslund, Denmark).
The measurements described below were performed on
inclusion and repeated after the intervention at 6 months
and at the follow-up 6 months later. In the training
group, the tests were also performed at 3 months.
Knee strength of the self-reported stronger leg was
measured on a Kin-Com dynamometer (Lumex Inc.,
Ronkonkoma, NY). Four familiarization trials followed by
six maximal trials were used to ensure that peak torque oc-
curred within the trials in all dynamic measurements. Max-
imal isokinetic concentric knee extension peak torques
were measured at an angular velocity of 60°/s followed by
180°/s, similarly, maximal isokinetic concentric knee flex-
ion peak torques were measured at 60°/s followed by
180°/s. Maximal isometric knee extension and knee flex-
ion strength were measured at an angle of 60° of knee flex-
ion (0°= full extension), the best of three trials. Data were
corrected for the effect of gravity of the shank and foot.
Maximal isometric trunk extension and flexion force
were measured on a strain-gauge force transducer (23)
(custom-built, August Krogh Institute, University of Copen-
hagen, Denmark) in an upright standing position. After fa-
miliarization with the testing procedure, trials were re-
peated until no further improvements were recorded.
Habitual walking speed followed by maximal walking
speed were measured along a 30-meter track approxi-
mately corresponding to the width of a wide urban street.
Participants were first asked to walk at their normal walking
pace from a standing position, and subsequently to walk as
fast as possible without running. No verbal encourage-
ment was given during the tests. Time was measured with
a stopwatch. Only one trial at each speed was carried out.
Balance was tested with the Berg Balance Scale (range
of total scores, 0-56 points) (24) and balance confidence
was estimated on a modified Activity-specific Balance
Confidence scale (a 14-item questionnaire, range of total
scores 0-100%) (25).
At baseline and 12 months later (6 months after the in-
tervention) participants were asked to rate their physical
activity level (PA) in one of four categories: 1. “Light PA
for less than 2 h/week”, 2. ”Light PA for 2-4 h/week”,
3. ”Light PA for more than 4 h/week or vigorous PA for
2-4 h/week” and 4. ”Vigorous PA for more than 4
h/week” (26).
In a subset of the participants, i.e., the final 26 par-
ticipants included in the study, the measurements de-
scribed below were performed on inclusion and at 6 and
12 months. Maximal leg extension power was measured
on a Nottingham Power Rig (27), with joint angles of the
foot, knee and hip similar to those occurring when a per-
son rises from a chair or walks upstairs. After familiar-
ization with the testing procedure, the maximal average
power produced of the self-reported stronger leg was
measured. Repeated chair stands, i.e., time to sit-and-
stand five times as rapidly as possible from a chair (6) and
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©2007, Editrice Kurtis

Table 1 - Training program.

Training components Remarks

Flexibility ~5 min Upper extremities, lower extremities and trunk range of motion
Warm up ~10 min Holding on to dumb-bells and walking on heels and toes, walking backwards and sideways and turning.
Swinging arms and legs and performing squats and knee lifts.
Shoulder, arm and hip exercises with resistance from elastic bands.

Muscle activity Load Sets x Reps Method

Standardized resistance exercise ~30 min

Leg extension/flexion 10RM 3 x 10 Bilateral leg press was performed in a leg press apparatus. The con-
centric phase was performed as quickly as possible, and eccentric ac-
tion was slow and controlled.
Hip extension 10RM 3 x 10 Standing hip extension (wall-mounted pulley system).
Ankle plantar flexion 10RM 3 x 10 Standing unilateral ankle plantar flexion with increasing load (weight
vest 1-9 kg).
Ankle dorsi-flexion max. 50 reps * Standing (leaning against a wall) bilateral ankle dorsiflexion.
2 x 30 * Step-ups (step height 20 cm)

Balance training ~10 min

Including standing (with eyes open or closed) with feet together, in semi-tandem position, tandem position, on one leg, on toes and heels. Walk-
ing on a line, lunging at various speeds, from slow motion to higher speed. Training items such as elastic bands and balls were used to add up-
per body manual tasks. Exercise difficulty was increased by exercising with or without shoes and on different surfaces, individually, in pairs or
with the whole group.

Stretching ~5 min
Especially of calf muscles, knee extensors and knee flexors.
Training was performed 1 hour twice weekly for 6 months. The training loads in the standardized resistance exercise module were evaluated every second week,
and increased to ensure that the same relative workload was maintained (70-75% of estimated one-repetition maximum (RM)). *The exercises of ankle dorsi-
flexion and step-ups were primarily training of muscle endurance.

stair-climbing time on a staircase consisting of 13 steps
were measured.
Finally, falls defined as “unintentionally coming to
rest on the ground, floor or other lower level” (28), were
monitored in all participants during the one-year study pe-
riod. A falls calendar was sent to every participant on the
first day of every month.
Primary outcome measures were knee extension
strength, walking speed, balance, and balance confidence.
Secondary outcomes were knee flexion strength, trunk
strength, leg extension power, chair stand and stair climb-
ing performance, falls, and physical activity level.
A similar age distribution in both groups was ensured
by using the minimization method with the aid of a com-
puter program (29) for randomization. To minimize the
potential adverse effects of non-blindedness of the tester
(the first author) the following steps were taken: ran-
domisation of participants to a training group who trained
for 6 months and a control group was achieved after com-
pletion of baseline tests. The tester did not supervise
training, and was blinded to the previous test results on the
subsequent test dates.
Training
The multidimensional training program (22) (Table 1)
was performed 60 minutes twice weekly for 6 months in
small groups (5-7 persons) and was supervised by a phys-
ical therapist in a small physical therapy gym. In the
first training session, participants were informed about the
age-related changes in muscle strength, endurance and
balance, and the potential consequences for activities of
daily living, and how exercise could potentially improve
physical capacity and make daily activities less strenuous.
Participants were also informed that fatigue and mild
training soreness after the first training bouts were signs
of a positive outcome. The physical therapists applied the
principles of self-efficacy, regular performance feedback
and positive reinforcement to enhance the motivation for
exercise progression (22).
Because of the heterogeneity of participants regarding
physical symptoms, the training program was slightly
personalized, to allow participants to make a pause when
needed. The resistance exercise was performed using a leg
press (Casall Sport AB, Norrkoping, Sweden) and a pul-
ley-system (Follo Industries AS, Aas, Norway). In the bi-
lateral leg press, the concentric phase was performed as
quickly as possible, to improve muscle power. The ra-
tionale for this was that leg extension power is a strong
predictor of functional limitations and disability in older
people, and that high-velocity resistance training can in-
crease lower extremity muscle power in older women with
self-reported functional limitations (30).

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©2007, Editrice Kurtis

The relative workload target in the resistance exercis- Statistics

es was 70-75% of the estimated one-repetition maximum,
and this was maintained throughout the training period as
strength improved.
No activities were provided for the control group but, af-
ter the one-year study period, they were offered the same
training program as the participants in the training group.
Based on results from a pilot study, the present study
was designed to have 80% power (α=0.05) with a drop-
out rate of 25%. Data are presented as means or medi-
an and standard deviations (SD), 95% Confidence In-
tervals, or range. To compare the groups on inclusion,
the Independent-Samples t-test, Mann-Whitney U test,

Contacted by phone Did not meet

(n=405) inclusion criteria
(n=144)

Met inclusion criteria Did not want

(n=261) to participate
(n=196)

Wanted to participate in study

(n=65)

Medical examination and baseline tests

(n=65)

Training group Control group

Withdrawals (n=32) (n=33) Withdrawals

Illness Wanted to train

(n=1) (n=1)
3-month training
(n=31)
Dropped out*
(n=3) Illness
illness 3-month tests (n=1)
(n=1) (n=27) Fracture
(n=1)
Ill spouse
Illness 3-month training (n=1)
(n=2) (n=24)
Fracture
(n=1)

Post intervention test 6-month tests

at 6 months (n=29)
(n=24)
Lost to follow-up
(n=2)
Follow-up test at 12 months Follow-up test at 12 months
(n=22) (n=29)

Fig. 1 - Trial profile. Of the 405 women who were contacted, 261 women were eligible. Reasons for ineligibility were: attending a medical
treatment program incompatible with participation in the project (n=57); Unable to walk unassisted outdoors (n=45); Cognitively impaired,
i.e., unable to carry on a conversation (n=19); Living in a summer cottage outside the Copenhagen area for most of the year (8); Living in
a residential home (n=7); Participated in another research project (n=3); Unable to speak Danish (n=3); Admitted to hospital (n=2). Of those
eligible, 196 did not want to participate in the study. 62 women were already physically active (training 1-7 h/w) and had been so for sev-
eral years. 134 women refused to participate, for a number of different reasons, including being too old, not having the energy required
for exercising, fearing that exercise would be harmful, not wanting to exercise, difficulty with public transport, and having to take care of
their spouse. ®= randomization. *3 subjects never commenced training, i.e., only participated in 1-3 training sessions.

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N. Beyer, L. Simonsen, J. Bülow, et al. Aging Clin Exp Res 19: 300-309, 2007
©2007, Editrice Kurtis

Chi-Square test and Fisher exact test were used, as ap- Table 2 - Baseline characteristics of participants.
propriate. All analyses of between-group effects were ad- Training group Control group p-value
justed for the number of medical diagnoses at baseline, (n=32) (n=33)
and baseline response values by including these as quan-
titative covariates in the models (ANCOVA). A repeated- Age (y) 78.6±5.1 77.6±4.4 p=0.391
measures ANCOVA was used to analyse between-group Height (cm) 160±6.4 160±7.4 p=0.683
effects at the follow-up 12 months later. The ANCOVA Weight (kg) 66.2±13.6 63.7±11.5 p=0.424
adjusted for the number of medical diagnoses at baseline BMI (kg/m2) 25.7±5.0 24.9±3.7 p=0.468
and baseline response values, was used in the inten- MMSE 27.9±2.0 27.6±2.0 p=0.595
tion-to-treat analyses, the last value being carried forward. Number of chronic 2 (0-5) 1 (0-4) p=0.033
diagnosis#*
Lastly, relationships between changes in different vari-
Number of medications# 2 (0-5) 2 (0-5) p=0.877
ables were evaluated using Spearman’s rho. All tests
VO2peak (ml/kg/min)+ 16.9±3.3 18.0±2.4 p=0.148
were two-tailed, with a chosen significance level of 0.05.
Isom. Knee Ext. 76.5±19.1 85.9±24.4 p=0.097
Analyses were performed with SPSS® for Windows, re- torque (Nm)
lease 13.0 (2004). Isokin. Knee Ext. 66.7±17.3 71.7±17.3 p=0.252
torque at 60°/s (Nm)
RESULTS Isokin. Knee Ext. 43.2±12.3 46.0±10.1 p=0.321
Sixty-five of the 261 eligible women were included in torque at 180°/s (Nm)
the study (Figure 1). One of the participants from the con- Isom. Knee Flex. 36.8±10.7 37.3±11.8 p=0.877
torque (Nm)
trol group withdrew, because she wanted to be in the
Isokin. Knee Flex. 31.0±12.9 35.3±14.9 p=0.229
training group. Eight participants from the training group torque at 60°/s (Nm)
and three from the control group withdrew for reasons un- Isokin. Knee Flex. 22.0±10.12 25.3±10.6 p=0.200
related to the intervention. These twelve participants did torque at 180°/s (Nm)
not differ from those who completed the study in any of Max. LEP (W)§ 69.1±22.5 78.8±50.9 p=0.553
the measured variables at baseline. Shortly after the Isom. Trunk Ext. strength (n) 210±74 245±102 p=0.126
baseline tests, three of the participants in the control Isom. Trunk Flex. strength (n) 220±65 239±65 p=0.265
group signed up for exercise classes offered to seniors by Habitual walking speed (m/s) 1.11±0.20 1.21±0.21 p=0.053
Senior Sports Associations, but they were not excluded Maximal walking speed (m/s) 1.35±0.27 1.49±0.27 p=0.055
from the study. Two of the participants in the training Chair Stand Time (s)§ 10.42±3.58 9.95±2.34 p=0.652
group were unwilling to undergo the follow-up tests 12 Stair Climbing Time (s)§ 8.01±2.06 7.03±1.21 p=0.151
months later (Figure 1). Balance, BBS (scale 0-56) 49.7±6.8 51.8±3.8 p=0.373
Participants’ characteristics are shown in Table 2. The ABC score (scale 0-100) 78.8±14.7 86.5±10.5 p=0.018
majority of the women belonged to social classes IV and V, Falls during prior year p=0.765
lived alone, and used no walking aid. Most of the index falls One fall (n) 21 22
had occurred outdoors, and in approximately 30% had re- Two+ falls (n) 11 11
sulted in a fracture of the arm. Results from the physical Index fall p=0.897
Indoors (n) 8 7
tests were on average poorer in the training group than in Outdoors (n) 21 22
the control group, but the variation was large and there In bus (n) 3 4
were no significant differences between the two groups, ex- Fracture of upper extremity (n) 11 11 p=1.000
cept for a greater number of chronic diagnoses and lower Walking aid (n) 4 6 p=0.733
balance confidence in the training group compared with the Living alone (n) 26 24 p=0.558
control group (p=0.033 and p=0.018, respectively). Co- Social class p=0.494
morbidity was present in 55 of participants. Bilateral knee I: Professional (n) 0 2
II: Intermediate (n) 5 4
osteoarthritis made it impossible to measure thigh muscle IV: Manually, partly skilled (n) 14 16
strength in three participants from the training group and V: Manually, unskilled (n) 13 11
one from the control group; also, due to osteoporosis, the Data are presented as means±SD or number of subjects. #Data presented as me-
muscle strength of the trunk was not tested in two partici- dian and range. *Average number of self-reported chronic diagnoses was sig-
pants from each group. nificantly higher in training group (Mann-Whitney U-test, p=0.033). Diagnoses
included (number of chronic diagnoses in training group/control group) cardio-
Results are reported for the 53 participants who com- vascular diseases (n=11/10), osteoarthritis (n=4/3), diabetes (n=0/1), pul-
pleted the intervention period. There were significant monary diseases (n=4/0), diseases of the spine (n=14/9), other (n=23/11), in-
between-group differences (Table 3) regarding isometric cluding rheumatic diseases, skin disease, Ménière’s disease, cancer, allergies, and
visual impairment. + VO 2 peak=Peak oxygen uptake; Isom.=isometric;
knee extension strength (p=0.011), dynamic knee flexion Isokin.=isokinetic; Ext.=extension; Flex.=flexion; BBS=Berg Balance Scale;
strength (p=0.001), trunk muscle strength (p=0.001), ABC=Activity-specific Balance Confidence scale; LEP=leg extension power; Chair
Stand Time=time to perform five chair stands; Stair Climbing Time=time to climb
balance performance (p=0.001), walking speed up stairs; §Results from a subset of participants.
(p=0.001), chair stand time (p=0.001), and stair climbing

304 Aging Clin Exp Res, Vol. 19, No. 4

Aging Clin Exp Res 19: 300-309, 2007 Improved strength and function after training in vulnerable old women
©2007, Editrice Kurtis

time (p=0.001). There were no significant differences re-
garding balance confidence (p=0.058), dynamic knee
extension strength (p=0.167 and p=0.631), isometric
knee flexion strength (p=0.056) or leg extension power
(p=0.091). Results from the 3-month test in the inter-
vention group showed that the greatest improvement
occurred during the first 3 months of training (data not
presented). Data from the training group showed a mod-
erate and significant relationship between improvements
in balance performance and self-reported balance confi-
dence (rs=0.513, p<0.001, n=24) and between changes
in habitual and maximal walking speed and balance per-
formance (rs=0.417, p=0.043 and rs=0.568, p<0.001,
n=24) and balance confidence (rs=0.570, p<0.01 and
rs=0.526, p<0.001, n=24), respectively.
Training compliance was on average 79% (42-100%).
Minor and transient symptoms in joints and tendinous
tissues were reported by some of the participants, es-
pecially at the beginning of the training period. The
symptoms elicited were related to participants’ chronic
conditions. Thus, the training program had to be mod-
ified for 1-3 training bouts because of symptoms in
the knee (n=2), hip (n=1), thigh and gluteal region
(n=2) and back (n=1). Additionally, it had to be modified
for 6 sessions for one participant who had chronic
pain in the groin and hamstrings, and occasionally in
one participant with chronic back pain. A pause in
training of one week was instituted for one participant
who experienced minor swelling of one ankle, and of
two weeks for one participant with knee pain.
Training loads were increased during the 6-month
training period, i.e., on average 162% (43-350%) in the
leg-press and 256% (67-500%) in hip extension. At 6
months, all participants were able to perform 50 repeti-
tions of unloaded bilateral ankle dorsiflexion, 2x30 step-
ups and 3x10 repetitions of unilateral ankle plantar flex-
ion (75% had an additional external load of 4-9 kg). In
comparison, the corresponding proportions of participants
who could perform the exercises at baseline were 8%,
50% and 13%.
Analyses of the complete datasets (0-6-12 months)
showed that the between-group effect were maintained
in most of the variables at the 6-month follow-up (Fig-
ure 2).
There was no between-group difference regarding
self-reported physical activity level (Table 4). The number
of women who fell during the one-year study period was
similar in the two groups. In both groups, eight women fell
once, and the number of women who fell 2+ times were
four in the training group (n=24) and six in the control
group (n=29).
The intention-to-treat analyses of primary outcome
measures showed significant between-group effects as a
result of intervention for isometric knee extension strength
(p=0.030), habitual walking speed (p<0.001) and maxi-
mal walking speed (p<0.001).

Table 3 - Changes in muscle function, physical performance and balance confidence during intervention period.

Training Group Control Group Estimated between-group

(N=24) (N=29) differences

Variables Baseline 6 mths Baseline 6 mths Mean (95% CI) p-value

Isom. Knee Ext.(Nm) 79.5±20.6 96.3±20.9 85.9±25.4 86.2±29.2 13.5 (3.3-23.7) p=0.011
Isokin. Knee Ext. 60 °/s (Nm) 69.0±17.9 79.3±13.8 70.1±17.8 71.5±22.6 5.7 (-2.5-13.8) p=0.167
Isokin. Knee Ext. 180 °/s (Nm) 45.1±12.5 51.4±10.0 45.5±10.7 49.0±12.3 1.1 (-3.6-5.9) p=0.631
Isom. Knee Flex. (Nm) 37.1±10.2 41.4±8.9 37.2±12.7 38.3±10.9 3.1 (-0.1-6.3) p=0.056
Isokin. Knee Flex. 60 °/s (Nm) 30.8±11.5 38.0±7.9 35.3±15.8 33.7±12.4 7.2 (2.9-11.4) p=0.001
Isokin. Knee Flex. 180 °/s (Nm) 22.4±9.5 31.3±12.2 24.9±11.1 24.9±10.0 8.1 (3.4-12.8) p=0.001
Isom. Trunk Ext. (n) 224±68 336±62 243±106 266±99 78 (45-111) p<0.001
Isom. Trunk Flex. (n) 236±66 313±62 242±69 253±67 55 (23-87) p=0.001
Habitual walking speed (m/s) 1.15±0.17 1.30±0.14 1.19±0.21 1.21±0.18 0.11 (0.04-0.17) p=0.001
Maximal walking speed (m/s) 1.41±0.22 1.55±0.20 1.47±0.28 1.47±0.22 0.13 (0.07-0.19) p=0.001
Balance, BBS (scale 0-56) 51.0±6.1 54.5±1.9 51.7±4.0 52.8±2.5 1.98 (0.85-3.10) p=0.001
ABC score (scale 0-100) 81.5±11.3 92.3±4.6 85.8±11.0 90.8±8.8 3.3 (-0.1-6.7) p=0.058
Results from a subgroup
Max. LEP (W)* 69±23 88±22 79±50 85±52 14 (-2-30) p=0.091
Chair Stand Time (s) 10.86±3.79 9.04±3.37 10.01±2.58 11.25±3.59 -3.3 (-1.6 - -5.0) p=0.001
Stair Climbing Time (s) 8.20±2.32 6.48±1.46 7.22±1.09 7.48±1.29 -1.47 (-0.70 - -2.24) p=0.001
Data are presented as means±SD. (ANCOVA, results were adjusted for number of medical diagnoses at baseline and baseline response values); Isom.=isometric;
Isokin.=isokinetic; Ext.=extension; Flex.=flexion; BBS=Berg Balance Scale; ABC=Activity-specific Balance Confidence scale; LEP=leg extension power; Chair
Stand Time=time to perform five chair stands; Stair Climbing Time=time to climb up stairs.

Aging Clin Exp Res, Vol. 19, No. 4 305

N. Beyer, L. Simonsen, J. Bülow, et al. Aging Clin Exp Res 19: 300-309, 2007
©2007, Editrice Kurtis

A - Knee extension strength B - Knee flexion strength

Isometric 60 deg/s 180 deg/s Isometric 60 deg/s 180 deg/s
120
50
100
40
Torque (Nm)

Torque (Nm)
*
80 ***
* 30
60 ***
20
40
10
0 0
0 6 12 0 6 12 0 6 12 0 6 12 0 6 12 0 6 12
Months Months Months Months Months Months

C - Isometric trunk strength D - Walking speed E - Balance F - Balance confid.

Extension Flexion Habitual Maximal
400 1.8 100
350 1.7

ABC score (max=100)

55

BBS score (max=56)

1.6 90
300 *** **
*** *** 1.5 ***
Speed (m/s)

250
Force (N)

1.4 80
50
200 1.3
1.2 ***
150 70
1.1 45
100 1.0
60
50 0.9
0 0.0 0 0
0 6 12 0 6 12 0 6 12 0 6 12 0 6 12 0 6 12
Months Months Months Months Months Months

Fig. 2 - Physiological and functional parameters in older women – before and after training and at 6-month follow-up. Data from train-
ing group (solid symbols) and control group (open symbols) are presented as means±SD. Hatched bars below x-axis: intervention period.
Significant between-group differences at 6-month follow-up: *p<0.05; **p<0.01; ***p<0.001 (Repeated-measures ANCOVA. Results
adjusted for number of medical diagnoses at baseline and baseline response values). Panel A: Isometric and isokinetic maximal knee ex-
tension strength (angular velocities of 60 deg/s and 180 deg/s), measured in 18 subjects from training group and 26 subjects from con-
trol group. Panel B: Isometric and isokinetic maximal knee flexion strength (angular velocities of 60 deg/s and 180 deg/s), measured in
18 subjects from training group and 26 subjects from control group. Panel C: Isometric trunk extension and flexion strength, measured
in 20 subjects from training group and 25 subjects from control group. Panel D: Habitual and maximal walking speeds, measured in 22
subjects from training group and 29 subjects from control group. Panel E: Balance, assessed with Berg Balance scale in 22 subjects from
training group and 29 subjects from control group. Panel F: Balance confidence, assessed with the modified Activity-specific Balance Con-
fidence score. Ratings were obtained in 22 subjects from training group and 29 subjects from control group.

DISCUSSION Nordic countries, concerning the number and types of

The primary findings of this randomized controlled study
were that 6 months of multidimensional training including
moderate resistance exercise and balance exercise resulted
in significant improvement in muscle strength and functional
performance in older home-dwelling women with a recent
fall history. Further, training induced improvements were pre-
served for 6 months after completion of the intervention,
most probably as a result of physiological improvement com-
bined with behavioural adaptations.
Most of the index falls had occurred outdoors, indi-
cating that participants in general were non-frail older
women (31). This was further supported by the fact that
they did not differ greatly from the general population in
their chronic diseases, intake of medication, and physical
activity level (26, 32). However, knee flexion strength,
trunk strength and leg extension power were on average
approximately 20-30% lower than those reported in
healthy older age-matched individuals (27).
Isometric knee extension strength improved as a result
of training, and reached a level which was comparable
with that reported in healthy older people (27). Like-
wise, trunk strength improved and the trunk extension to
flexion strength ratio increased, corresponding to that ob-
served in younger healthy individuals (33). This ratio
may imply a more favorable relation between agonist
and antagonist muscles, which is important for postural

306 Aging Clin Exp Res, Vol. 19, No. 4

Aging Clin Exp Res 19: 300-309, 2007 Improved strength and function after training in vulnerable old women
©2007, Editrice Kurtis
Table 4 - Level of physical activity.
Physical activity 6-month follow-up
Training group
(n=22)
>4 h/w 2-4 h/w
1 2
Baseline
>4 h/w 1 6
2-4 h/w 2 7 4 1
<2 h/w 3 2
Self-reported physical activity level (PA) at baseline and 12 months later: <2h/w=light PA for less than 2 h/week; 2-4h/w=light PA for 2-4 h/week, >4h/w=light
PA for more than 4 h/week or vigorous PA for 2-4 h/week.
stability during everyday activities. Improvements in iso-
metric strength of thigh and trunk muscles are of impor-
tance for independent living and activities such as walking
(34) and rising from a chair (3), since decreased thigh and
trunk strength are predictors of disability (35).
We found no significant between-group differences
in dynamic knee extension strength or isometric knee flex-
ion strength (Table 3). Nor did we find any between-
group differences in the measurement of leg extension
power (Table 3), although the average increase in leg ex-
tension power was 33% as a result of training. The 95%
confidence limits of the estimated between-group differ-
ences suggest that there may be an effect of training.
Hence, the lack of between-group effect in these mea-
surements of muscle strength and power may be due to
the relatively small sample size and great variations in
torque in weaker elderly people (36).
All improvements in functional performance, i.e.,
chair rise, stair climbing and walking speed as a result of
training, were directly related to daily life activities. The in-
crease in maximal walking speed from 1.41 m/s (0.91-
1.77 m/s) to 1.55 m/s (1.21-2.02 m/s) is of practical im-
portance, because traffic-light phases in Denmark are
based on a walking speed of 1.35 m/s to 1.5 m/s, and
the minimum speed required is 1.00 m/s. Thus, the rel-
ative effort of crossing streets was smaller and anecdotally
associated with a greater sense of security. In addition, a
higher walking speed may be associated with a decreased
risk of disability in community-dwelling older people who
are not cognitively impaired (6).
It could be argued that the improvements found in the
present study were due to the low starting point of the
training group. However, habitual walking speed was
the only parameter for which delta values were inversely
associated with baseline values.
Although the participants in the present study were in-
cluded after a fall accident, the majority had high BBS
scores on inclusion. This is in agreement with a study in
which outdoor falls were associated with compromised
Physical activity 6-month follow-up
Control group
(n=29)
<2 h/w >4 h/w 2-4 h/w <2 h/w
3 1 2 3
Baseline
>4 h/w 1 10 1
2-4 h/w 2 3 7 3
2 <2 h/w 3 2 2 1
health in more active older people (31). Balance perfor-
mance improved as a result of training, but a ceiling effect
was found after three months and, consequently, we
may not have been able to document the true improve-
ment in balance performance. The relationships between
improvements in balance performance, balance confi-
dence and walking speed as a result of training indicate
that lack of balance confidence and slow walking speed
may reflect a rational assessment of participants’ personal
risk in activities considered to be potential hazards. We
had expected to find a correlation between increases in
strength and balance performance, but there was none,
perhaps due to the ceiling effect on the Berg Balance
scale, which made improvements above a certain level im-
possible to measure.
In contrast with balance performance, we found no be-
tween-group effect regarding balance confidence, al-
though the p-value approached significance (p=0.058).
This was probably because balance confidence improved
in the control group during the intervention period. Sim-
ilarly, a reduction of the fear of falling had previously been
found in an observation study of patients hospitalized
after a fall accident (37). However, the results from the 6-
month follow-up showed a between-group effect, indi-
cating that improvements in balance confidence persist-
ed to a higher degree in the training group throughout the
observation period (Figure 2).
Most of the improvements as a result of training were
preserved at the 6-month follow-up (Figure 2). Although
we did not find any between-group differences regarding
level of physical activity (Table 4), the preservation of the
between-group effects 6 months after the completion
of training (Figure 2) may have been the result of increased
physical activity in the training group (38). No differ-
ence may have been noted because of the very crude
measurement method used in the present study.
There was no significant difference in the number of falls
between the groups. Numerous studies have shown that the
risk of falling is increased in those who have previously ex-
Aging Clin Exp Res, Vol. 19, No. 4 307
N. Beyer, L. Simonsen, J. Bülow, et al.
perienced a fall (39) but, in our study, the prevalence of falls
in the observation period was similar to that found in a study
of the normal population (40). In both training and control
groups several of the participants were more physically ac-
tive at the 6-month follow-up compared with baseline
(Table 4). Anecdotally, it was the authors’ impression that,
after completion of the baseline tests, most participants were
pleasantly surprised about their test results. This may explain
why some of the participants in the control group in-
creased their physical activity level and why most of the
measured variables remained unchanged over the one-
year study period, and some even showed a small nu-
merical improvement (Figure 2).
Compliance and adherence to training in the present
study were similar to those found previously with a simi-
lar intervention period (18). The few subjects (9%) who lost
interest in the training did so within three training bouts.
The rest of the withdrawals were due to medical condi-
tions, and this must be anticipated when the study group
consists of elderly people with co-morbidity. Nevertheless,
the intention-to-treat analysis showed between-group ef-
fects as regards isometric knee extension strength and
walking speed, which are some of the most important
common risk factors for falls and disability. The intention-
to-treat analysis did not show any between-group effect re-
garding balance performance, as we had hypothesized, but
this may have been caused by the ceiling effect on the
Berg Balance test.
The present study has some limitations. The main
one is the relatively small sample size. Furthermore, no
activities were offered to the control group, and only
women who came to the sessions were included. The
latter implied a selected study group, since quite a num-
ber of the women contacted had difficulty with public
transport. Hence, the results cannot be generalized to
men or frail home-dwelling women who present at the
accident and emergency clinic. However, the fact that
training took place in a hospital setting and was super-
vised by physical therapists may be of importance, be-
cause they are thought to provide safe exercise in-
structions tailored to individual needs. Thus, training su-
pervised by health professionals may be even more
important for older people with lower levels of educa-
tion, who are known to be more sedentary than those
with higher levels of education. Lastly, providing trans-
port free of charge to the exercise premises may be cru-
cial for compliance and adherence.
In conclusion, a multidimensional training program
produced significant improvements in physiological and
functional risk factors for falls and disability in women aged
70-90 years with a recent history of falls. The program
proved to be efficacious even at the 6-month follow-up
concerning muscle strength, walking and balance, but not
falls. Furthermore, the intention-to-treat analyses showed
that there were significant between-group effects of train-
308 Aging Clin Exp Res, Vol. 19, No. 4
Aging Clin Exp Res 19: 300-309, 2007
©2007, Editrice Kurtis
ing with regard to isometric knee extension strength and
walking speed.
The type of intervention we introduced appears to be
a practical way of counteracting the physical decline of
older people at risk, and thereby potentially prevent or de-
lay disability. Targeting non-frail older people with a recent
fall history may be a productive strategy, because re-
stricted activity is an important predictor of functional de-
cline in older persons who are not otherwise at high
risk for ADL disability (13).
ACKNOWLEDGMENTS
We thank Associate Professor Lene Theil Skovgaard, Depart-
ment of Biostatistics, University of Copenhagen, for expert support in
statistics. The project was partly supported with funds from the Dan-
ish Medical Association Research Fund, Danish Medical Research
Council (22-01-0154), Novo Nordisk Foundation, and The Association
of Danish Physiotherapists Research Fund.
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