ORIGINAL ARTICLE
Efﬁcacy of training program for ambulatory competencein elderly women
Jun Iwamoto,1,2 Yohei Otaka,2 Kazuhiko Kudo,2 Tsuyoshi Takeda,1 Mitsuyoshi Uzawa2 andKiyoshi Hirabayashi2
1Department of Sports Medicine, School of Medicine, Keio University Tokyo
2Keiyu Orthopaedic Hospital, Gunma, Japan(Received for publication on December 15, 2003)

Abstract. The optimal prevention of osteoporotic fractures in the elderly consists of increasing thebone density and preventing falls. We report on the efﬁcacy of training program to promote ambulatory competence in elderly women. Twenty-ﬁve elderly women were enrolled in our training program,which is a three-month program consisting of dynamic balance training with Galileo 900 (Novotec,
Pforzheim, Germany) once a week, combined with daily static balance (standing on one leg like a ﬂamingo) and resistance (half-squat) trainings. The mean age of the participants was 72.8 years (range,
61–86 years). After 3 months of training, the step length, knee extensor muscle strength, and maximum
standing time on one leg were signiﬁcantly increased, while the walking speed and hip ﬂexor muscle
strength were not signiﬁcantly altered. During the study period, no serious adverse events such as newvertebral fractures or adverse cardiovascular symptoms were observed in any participant. The present
preliminary study shows that our training program may have the potential to promote ambulatorycompetence in elderly women. (Keio J Med 53 (2): 85–89, June 2004)
Key words: elderly women, fall, balance training, strength training, walking ability

prevention of falls in the elderly. However, randomized
controlled trials have not consistently shown beneﬁcial
effects of exercise on fall prevention,3–5 and the efﬁcacy
of exercise for promoting ambulatory competence andpreventing falls in the elderly has not yet been unequivocally established. Strategies for the prevention of
falls, as well as for the management of osteoporosis in
the elderly still need to be established.
Recently, vibration training has been developed as a
new modality in physiotherapy. It has been suggested
that vibration training possibly increases muscle power
in athletes,6 and muscle blood volume in healthy
adults,7 and improves muscular performance and bodybalance in young healthy subjects.8 Although highintensity vibration training may increase both themuscle strength and volume in young subjects, we surmise that low-intensity vibration training may have agreater potential to promote ambulatory competence inelderly women with an increased risk of falls, by stimulating the neuromuscular system.6
Low-intensity vibration training once a week may be

Introduction
Fall-related injuries, e.g., hip fractures are serious
problems in the elderly with osteoporosis. Osteoporosis is known to be especially common among elderly
women. The incidence of spinal fractures increases withage after menopause in women, and the incidence of
hip fractures increases exponentially after 80 years ofage in elderly women. More than 90% of hip fractures
result from a fall.1 Falls are also becoming increasingly
common among the elderly, so that up to 80% of all
80-year-olds sustain at least one fall per year.2 Whilethe life expectancy of women is higher than that of men,the proportion of those who are functionally independent is higher in elderly women than in men, which is
known as the ‘‘gerontologic paradox.’’ Thus, prevention of trauma, i.e., injuries by falls would reduce disability, improve the quality of life, and reduce the costof treatment for fall-related injuries, especially in elderly
women with osteoporosis.
Exercise is generally thought to be effective for the

Reprint requests to: Dr. Jun Iwamoto, Department of Sports Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku,
Tokyo 160-8582, Japan, e-mail: jiwamoto@sc.itc.keio.ac.jp85

86

Iwamoto J, et al: Fall prevention in elderly womensafe, easy to practice, and easy to continue in the elderly, and may promote ambulatory competence,
including by improving balance and muscle strength,
more effectively when combined with daily static balance and resistance training. We report on the efﬁcacyof our three-month training program consisting of onceweekly dynamic balance training with the Galileo system (Novotec, Pfozheim, Germany), combined withdaily static balance and resistance training, aimed topromote ambulatory competence in elderly women.
Subjects and Methods
Twenty-ﬁve elderly women, who visited our hospitalduring the 3 months between October and December in
2002, were recruited to our training program. The program consisted of dynamic balance training with theGalileo 900 (frequency, 20 Hz; duration, 4 minutes)
once a week, combined with daily static balance training (standing on one leg like a ﬂamingo for one minute:‘‘Flamingo exercise’’) and resistance training (10 setsof half-squats) daily. Tables 1 and 2 show the characteristics and physical ﬁtness of the participants, respectively. The training program was administered for 3
months, and all the participants completed the program.
None of the participants experienced any fall during thestudy period.
All data are presented as means plus/minus standard deviation (SD). The correlation of age with ambulatory competence and grip strength was examinedby single regression analysis. The longitudinal changes
in the parameters were evaluated by one-way analysis
of variance (ANOVA) with repeated measurements.
All statistical analyses were performed using the Stat
View J-5.0 program (SAS Institute, Cary, NC, USA)on a Macintosh computer. The signiﬁcance level of
P < 0:05 was used for all comparisons.
Results
Figure 1 shows the correlation of age with theambulatory competence and grip strength. Age wassigniﬁcantly positively correlated with the 10-meterwalking time (r ¼ 0:622, p < 0:001) and signiﬁcantly
negatively correlated with the step length (r ¼ 0:661,
p < 0:001). However, no signiﬁcant correlation was
found between age and the maximum torque of theknee extensor and hip ﬂexor muscles, maximum standing time on one leg, or grip strength.
Figure 2 shows the changes in the ambulatorycompetence and the grip strength. The step length,
maximum torque of the knee extensor muscle, andmaximum standing time on one leg were found to havesigniﬁcantly increased by 4.5%, 6.8%, and 72.5%, re-Table 1

Characteristics of ParticipantsAge (years)
Height (cm)Body weight (kg)BMI (kg/m 2 )Lumbar BMD (g/cm 2 )T score of Lumbar BMD (%)
Number of prevalent vertebral
fractures
Number of falls during one year prior
to the study

72:8 G 7:0
144:7 G 6:8
48:3 G 8:0
23:0 G 3:2
0:616 G 0:118
61:7 G 11:9
3:2 G 3:1

(61–86)(132.2–162.6)(35.9–61.6)(16.7–29.9)(0.314–0.785)(31–77)(0–9)

0:52 G 1:26

(0–6)

Data are expressed as means G SD. Numbers in parenthesis arerangers. BMI: body mass index, BMD: bone mineral density. BMD
was measured by dual energy X-ray absorptiometry using a Hologic
QDR 1500 W (Bedford, MA, USA). Vertebral fractures were evaluated at the T4–L5 level using the Japanese criteria for vertebral
fractures.9,10

Table 2

Physical Fitness of Participants

Ten-meter walking time (sec)
Step length (cm)
Maximum torque
Knee extensor muscle (N)Hip ﬂexor muscle (N)Maximum standing time on
one leg (sec)
Grip strength (kg)

11:6 G 5:2
53:5 G 9:7(5.9–15.2)(37.0–76.9)

133:3 G 28:7
105:8 G 30:5
10:2 G 13:0

(73–91)(48–189)(0–60)

17:0 G 4:7(5.0–29.0)

Data are expressed as means G SD. Numbers in parenthesis areranges. The maximum torques of the muscles were measured byPower Track II Commander (Japan Medix, Tokyo, Japan) andgrip strength was measured by Smedley’s Hand Dynamometer. All
parameters were measured three times and the mean values wereobtained. All parameters for the extremities were obtained from thenon-dominant side.

spectively, while the 10-meter walking time and maximum torque of the hip ﬂexor muscle were not signiﬁcantly altered. During the study period, no serious
adverse events such as new vertebral fractures or adverse cardiovascular symptoms were observed in any
participant.
Discussion
The results of the present study showed that thewalking speed and the step length were correlated withthe age of the subject, and that our training program
increased the step length, knee extensor muscle power,
and maximum standing time on one leg in the subjects.
Age-related decrease in the muscle strength is known
to be much more marked in the lower extremities thanin the upper extremities,11 and gait in the elderly isKeio J Med 2004; 53 (2): 85–89

87

Ten-meter walking time

Max torque of hip flex muscle(sec) 35

(N) 200

30
25

r = + 0.622(P<0.001)

20
15
10
5
60

65

70

75
age

80

85

90

r = - 0.176
(N S)
60

65

70

75
age

80

85

90

Max standing time on one leg

Step length
(cm)

180
160
140
120
100
80
60
40

(sec) 70

75
70
65
60
55
50
45
40
35
30

r = - 0.661(P<0.001)
60

65

70

75
age

80

85

60
50
40
30
20
10
0
- 10

r = - 0.235
(N S)
60

90

Max torque of knee ext muscle

65

70

75
age

80

85

90

Grip strength(kg) 27.5(N) 200

180
160
140
120
100
80
60

r = - 0.295
(N S)
60

65

70

75
age

80

85

90

25
22.5
20
17.5
15
12.5
10
7.5
5
2.5

r = - 0.277
(N S)
60

65

70

75
age

80

85

90

Fig. 1 Correlation of age and physical ﬁtness. The correlation of age with the ambulatory competence and grip strength was examined bysingle regression analysis. Age was signiﬁcantly positively correlated with the ten-meter walking time and signiﬁcantly negatively correlatedwith the step length. However, no signiﬁcant correlation was found between age and the maximum torque of the knee extensor and hip ﬂexor
muscles, maximum standing time on one leg, or grip strength.

characterized by a decreased step length and step
width.12 Impairment of muscle strength of the lower
extremities, balance/postural control, and gait has beenfound to be important risk factors for falls.1 While wefound age-related impairment of gait in elderly womenwith osteoporosis, we could not detect any age-relatedchanges in the strength of the knee extensor and hip
ﬂexor muscles in these subjects, probably because thesample size in the study was small and younger women
without disability were not included.
The optimal prevention of osteoporotic fractures inthe elderly consists of increasing bone density and preventing falls. With regard to fall prevention, objective
measures of balance and muscle strength that meetthe criteria of reliability and validity are required as
the bases for exercise regimens. However, randomized
controlled trials have not consistently shown beneﬁcial
effects of exercise on fall prevention.3–5 The reason
for this may be that the type, duration, frequency, andintensity of the exercise components varied across thestudies. In particular, one or more of endurance,
resistance, and static and dynamic balance training wasadministered. Of the balance exercises, Tai Chi has
proved to be the most successful for decreasing the

likelihood of falls.13,14
Whole-body vibration training with Galileo wasdeveloped as a new modality in physiotherapy. Galileo
is a unique device for applying whole body vibration/
oscillatory muscle stimulation. The subject stands withbent knees and hips on a rocking platform with a sagittal axle, which alternately thrusts the right and left leg
0.7–4.2 mm upwards and downwards at a frequency of
20 Hz, thereby stretching of the extensor muscles ofthe lower extremities. The reaction of the neuromuscular system is a chain of rapid muscle contractions. This
type of training provides reﬂex muscle stimulation to
improve balance and possibly the muscle strength, withno serious side effects.
The type of exercise that is considered to be safe,
well-tolerated, and sustainable in the elderly, is mild
static and dynamic balance, and mild resistance trainings. Based on this view, our training program consistedof once-weekly dynamic balance training using Galileo,
combined with daily static balance training (standing on
one leg) and resistance training (half-squat training).
These training sessions were administered to produce astable gait, and during the study period, no serious adverse events such as new vertebral fractures or adverse

88

Iwamoto J, et al: Fall prevention in elderly women

(sec)
18

Ten-meter walking time

16

120

12

NS

10

67.5
65
62.5
60
57.5
55
52.5
50
47.5
45
42.5

(N)
180
170
160
150
140
130
120
110
100

110

NS

100
90

8

(cm)

Max torque of
hip flex muscle

130

14

6

(N)
140

80
0

3

Month

(sec)

Step length
P<0.01

0

3

70

40
35
30
25
20
15
10
5
0
-5

Month

Max torque ofknee ext muscle

(kg)
24

0

3

Month

Max standing timeon one leg

P<0.05

0

3

Month

Grip strength22
20

P<0.01

NS

18
16
14
12

0

3

10

Month

0

3

Month

Fig. 2 Changes in physical ﬁtness. All the data are presented asmeans G SD. The longitudinal changes in the ambulatory competence
and grip strength were examined by one-way analysis (ANOVA) withrepeated measurements. The step length, maximum torque of theknee extensor muscle, and maximum standing time on one leg were
found to have signiﬁcantly increased, while the ten-meter walking
time and maximum torque of the hip ﬂexor muscle were not signiﬁcantly altered.

cardiovascular symptoms were observed in any participant.
Our training program increased the step length,knee extensor muscle strength, and maximum standingtime on one leg, but no improvements were found in
the walking speed or hip ﬂexor muscle strength. We
tried to measure the hip abductor muscle strength, but
could not obtain any valuable data in most of the participants, because of severe age-related impairment of
the hip abductor muscle. With regard to the effect of
exercise on the ambulatory competence in the elderly, a
few studies have been reported.1,15,16 Buchner et al.15
reported that the combination of aerobic and anaerobic
training in the elderly with mild gait disturbance prevented falls despite no signiﬁcant improvement of muscle strength and body balance. On the other hand,
Runge et al.1 reported that whole-body vibration training with Galileo decreased chair rising time as a resultof increased muscle power caused by reﬂex muscle
stimulation in geriatric patients without serious adverse
events. Muto et al.16 reported that their original training program consisting of various types of gymnastic
training protocols, improved the walking speed andmaximum standing time on one leg. Thus, the reported
effects of exercise on the ambulatory competence vary
among different studies. The reason for this could be
the different type of exercise training protocols anddifferent parameters assessed among different studies.
Muscle weakness and poor balance underlie most falls,
and strength training against resistance and dynamicbalance training have been suggested to improve bothstrength and balance.3 Thus, combination training withstrength and balance training appears to be required toprevent falls.
Because our training program consisted of the combination of three types of exercise training, it remains
uncertain which one most signiﬁcantly improved balance and muscle strength. Half-squat training (resistance training) was aimed at increasing knee extensor
muscle strength, while Flamingo exercise (static balance training) was aimed at increasing maximum
standing time on one leg. Whole-body vibration training (dynamic balance training) was aimed at stimulating neuromuscular system, promoting balance, andpossibly increasing the muscle strength in the lower
extremities. Thus, the increases in the knee extension
muscle strength and standing time on one leg might
have been a result of the combined effects of all three
types of training.
On the other hand, the reason for the increase in
the step length remains uncertain. Basically, each stride
during walking consists of the stance and swing phases.
Thus, increased maximum standing time on one leg andknee extensor muscle strength can produce a more stable gait. That is, the more the stance phase of each leg
was stabilized by training, the greater the swing of theother leg became, resulting in an increase in step length.
Because impaired gait in the elderly is possibly associated with decreased step length, the increased step
length may also indicate improved ambulatory competence. In order to signiﬁcantly increase the walking
speed, endurance training using bicycle or walking
training might be needed.
The limitations of the present study should be discussed. First, there were no control groups. Thus, only
longitudinal changes of ambulatory competence fromthe baseline were available only in the trained subjects.
Second, the sample size might have been too small for
detecting the signiﬁcance of the longitudinal increases
in the walking speed. Third, the duration of the training
program might have been too short for the efﬁcacy ofour program for fall prevention to be unequivocallyestablished. Further studies may be needed to conﬁrm
the efﬁcacy of our program for musculoskeletal healthin elderly women.
In conclusion, the present preliminary study showsthat our training program may have the potential topromote ambulatory competence in elderly women.
Acknowledgments: We thank Drs. Tadashi Ugajin, Koichi Kurakami,
Michiko Kameda, and Tistuo Morita for collecting the data on thephysical ﬁtness of the participants.

Keio J Med 2004; 53 (2): 85–89

References
1. Runge M, Rehfeld G, Resnicek E: Balance training and exercise in geriatric patients. J Musculoskel Neuron Interact 2000; 1:
61–65
2. Armstrong AL, Wallace WA: The epidemiology of hip fracturesand methods of prevention. Acta Orthop Belg 1994; 60: 85–101
3. Gardner MM, Robertson MC, Campbell AJ: Exercise in preventing falls and fall related injuries in older people: a review of
randomized controlled trials. Br J Sports Med 2000; 34: 7–17
4. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH: Interventions for preventing falls in elderly
people. Cochrane Database Syst Rev 2001; 3: CD000340
5. Province MA, Hadley EC, Hornbrook MC, Lipsitz LA, Miller
JP, Mulrow CD, Ory MG, Sattin RW, Tinetti ME, Wolf SL: The
effects of exercise on falls in elderly patients. A preplanned
meta-analysis of the FICSIT trials. JAMA 1995; 273: 1381–1383
6. Bosco C, Cardinale M, Tsarpela O: Inﬂuence of vibration onmechanical power and electromyogram activity in human arm
ﬂexor muscles. Eur J Appl Physiol Occup Physiol 1999; 79:
306–311
7. Kerchan-Schindl K, Grampp S, Henk C, Resch H, Preisinger E,
Fialka-Moser V, Imhof H: Whole-body vibration exercise leads
to alterations in muscle blood volume. Clinical Physiology 2001;
3: 377–382
8. Torvinen S, Kannus P, Siebanen H, Jarvinen TA, Pasanen M,
Kontulainen S, Jarvinen TL, Jarvinen M, Oja P, Vuori I: Effectof a vibration exposure on muscular performance and bodybalance. Randomized cross-over study. Clin Physiol & Func Im
2002; 22: 145–152

89
9. Orimo H, Sugioka Y, Fukunaga M, Muto Y, Hotokebuchi T,
Gorai I, Nakamura T, Kushida K, Tanaka H, Ikai T, Oh-hashi Y:
Diagnostic criteria of primary osteoporosis. J Bone Miner Metab
1998; 16: 139–150
10. Orimo H, Hayashi Y, Fukunaga M, Sone T, Fujiwara S, Shiraki
M, Kushida K, Miyamoto S, Soen S, Nishimura J, Oh-hashi Y,
Hosoi T, Gorai I, Tanaka H, Igai T, Kishimoto H: Diagnostic
criteria for primary osteoporosis: year 2000 revision. J Bone
Miner Metab 2001; 19: 331–337
11. Asmussen E: Aging and exercise. Environ Physiol 1980; 3:
419–428
12. Hoshino K, Beppu M, Ishii S, Masuda T, Hibino Y, Oyake Y,
Aoki H, Sudou K, Iida Y: The gait analysis of the elderly at thefall prevention exercise class. J Physical Medicine 2002; 13: 113–
117 (in Japanese)
13. Lane JM, Nydick M: Osteoporosis: current modes of prevention
and treatment. J Am Acad Orthop Surg 1999; 7: 19–31
14. Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu
T: Reducing frailty and falls in older persons: an investigation of
Tai Chi and computerized balance training. J Am Geriatr Soc
1996; 44: 489–497
15. Buchner DM, Cress ME, de Lateur BJ, Esselman PC, Margherita AJ, Prince R, Wagner EH: The effect of strength andendurance training on gait, balance, fall risk, and health services
use in community-living older adults. J Gerontol A Biol Sci Med
Sci 1997; 52: M218–M224
16. Muto Y, Ohta M, Kuroyanagi R, Ueno K, Tanaka N, Komatsu
T, Kamioka H, Okada S, Sayano A: Medical approach to prevention of falls among the elderly. J Physical Medicine 2002; 13:
98–105 (in Japanese)