Volume 3, Issue 2, June 2018

The need to be fit, strong, fast and agile has been an evolutionary requirement since early history. In this paper we identify the effectiveness of different types of physical activity on muscle, bone and balance outcomes, and what types of physical activity contribute to the development and maintenance of these outcomes. We undertook a purposive search of PubMed, international evidence reviews of physical activity, and asked international experts to identify review level relevant literature on the effectiveness of muscle, bone and balance training and physical activity on health outcomes. We found consistent review level evidence that strength/resistance training as a single intervention or in combination with other activities, two/three occasions per week, were effective for muscular strength, with higher intensities of training producing greater gains. We found consistent review level evidence that strength training as a single intervention or in combination with high impact loading activities taken at least 3 times per week were effective for bone health. Physical activities with a high challenge to balance done in standing three times per week were beneficial for balance training and falls reduction. The current UK 2011 Chief Medical Officer’s physical activity guidelines remain consistent with the most up to date review level evidence for muscle and balance health.

Many activities of daily living require muscular strength and power as well as balance. Consequently, preserving musculoskeletal function is a prerequisite for maintaining mobility and independent living during ageing. Estimates suggest that the prevalence of physical activity guidelines for strength and balance is low. Review of reviews of: a) observation studies of the prospective association between measures of musculoskeletal fitness and health outcomes and b) randomised controlled trials of resistance, balance and skeletal impact training exercises on bone health, risk of falls, physical function, motor and cognitive function, quality of life and activities of daily living. Preserving muscular strength/power in middle and older age is associated with a reduced risk of all-cause and cardiovascular mortality. Impaired muscular strength/power and balance is associated with an increased risk of falls and lower bone mineral content. Regular supervised exercise incorporating high intensity resistance training, vertical impacts and a balance challenge are most likely to be beneficial to health and wellbeing, bone health and reduce the risks of falls. Adults in late middle and older age would benefit from a regular program of exercise that incorporates high intensity resistance training, impact exercises and balance challenges.

This narrative review focuses on the role of strength and balance activities throughout the lifecycle to improve physical capacity and reduce all-cause mortality. The evidence suggests strong associations in middle and older age, with poor balance, poor strength or poor physical function having strong associations with mortality. Currently in the UK, the proportions of adults (69% of men and 76% of women) not meeting the strength and balance guidelines (of 2 or more sessions/week) is concerning. This report identifies specific time points in the lifecycle where specific promotion of and engagement with strength and balance activities would be most beneficial for health: 18-24y to maximize bone and muscle mass gains, 40-50y to maintain strength and reduce that downward cycle, and over 65s to preserve balance and strength and maintain independence). This review also suggests specific transition points/events in life where there may be an increase in sedentary behaviour or loss of muscle function (pregnancy, menopause, onset of on diagnosis of disease, retirement, on becoming a carer and following hospitalization), where it would be useful to initiate additional strength and balance exercises to improve future health outcomes.

Physical activity guidelines advocate the inclusion of strength and balance activities, twice a week, for adults and older adults, but with caveat that in some individuals there will be certain movements and activities that could lead to adverse events. This scoping review summarizes the evidence about how safe and efficacious these activities are in older adults with specific challenges that might make them more prone to injury (e.g. having recently fractured or at risk of fracture (osteoporosis) or those who are frail or who have cognitive impairment). The review identified that for prevention of falls in people with a falls history and/or frailer older adults, structured exercise programmes that incorporate progressive resistance training (PRT) with increasing balance challenges over time are safe and effective if performed regularly, with supervision and support, over at least 6 months. Some minor adverse effects mainly transient musculoskeletal pain) have been reported. For those with a higher risk of falls and fractures (very poor balance, vertebral fractures), supervised structured exercise programmes are most appropriate. People with diagnosed osteoporosis should be as active as possible and only avoid activities with a high risk of falls if they are naive to those activities. For those in transition to frailty who have poor strength and balance, exercises that are known to help maintain strength and balance (such as Tai Chi) are effective in preventing a decline in falls risk. For the very frail older adult, supervised structured exercise that has PRT, balance training and some endurance work, supervised and progressed by a trained person are advocated.

Objectives

This review sought to investigate the question: what are the key barriers to, and enablers for, older adults undertaking muscle strengthening and balance activities, and how can these be addressed by individuals and practitioners?

Methods

A search of PubMed for review-level evidence on professional and personal barriers and motivators for strength and balance activities among older people.

Results

The search and expert consultation found 46 studies; after screening, twelve papers were included. Many of the barriers and motivators to strength and balance activities are familiar ones that can also apply to physical activity more generally, such as not having the time. More specific barriers to strength and balance activities for older people were perceived risk of a heart attack, stroke, or death, and fear of looking too muscular; with motivators being improved ability to complete daily activities, preventing deterioration and disability, and decreasing the risk or fear of falling.

Conclusions

This review of reviews has found a small but consistent body of literature describing the motivators and barriers to older adults taking part in strength and balance activities. This may be used as the basis for planning and delivering physical activity programmes for older adults.

Introduction

Despite the importance of muscle strengthening and balance activities for health, these elements of the physical activity recommendations are often omitted from communication campaigns and national surveillance systems. This paper reviews national physical activity surveillance systems to determine which tools assess muscle strengthening and balance activities.

Methods

We reviewed each tool that was used to inform the Global Observatory for Physical Activity (GoPA) country card prevalence estimates.

Results

Of the 139 countries with GoPA country cards, 21 countries reported having no physical activity prevalence data. The prevalence estimates for 74 countries came from the World Health Organization 2014 Global Status Report on Non-Communicable Diseases. For the remaining 44 countries, a range of national and international surveys were used. A limited number of tools sought to assess muscle strengthening activities, and even fewer assessed balance and coordination activities.

Discussion

Several issues arise from this review, including the need to: verify the strength of the evidence to inform whether muscle strength and balance should be given equal prominence to the aerobic recommendation; establish which activities count towards different aspects of the guidelines; and confirm whether the muscle strengthening and balance components of the guidelines are ‘in addition’ to the aerobic component.