Predictive ability of a self-rated fall risk assessment tool in community-dwelling older women.

BACKGROUND: Falls are a substantial health problem among older adults. An accessible and reliable tool for assessing individual fall risk is needed. AIMS: The predictive ability of a one-page self-rated fall risk assessment form (KaatumisSeula® [KS]) was evaluated among older women in its current form. METHODS: A subsample (n = 384) of community-living older women (aged 72-84 years) participating in the Kuopio Fall Prevention Study (KFPS) completed the KS form. Participants' falls were prospectively registered for 12 months with SMS messages. Their group status and form-based fall risk category were compared to the verified fall events during the KFPS intervention. Negative binomial regression and multinomial regression analyses were used. Physical performance measurements (single leg stance, leg extension strength and grip strength) were used as covariates. RESULTS: During the follow-up, 43.8% of women fell at least once. Among the fallers, 76.8% had at least one self-determined injurious fall, and 26.2% had falls requiring medical attention. According to KS, 7.6% of the women had low fall risk, 75.0% moderate, 15.4% substantial, and only 2.1% high fall risk. Women in the "moderate fall risk" group had 1.47-fold (95% CI 0.74-2.91; nonsignificant), in "substantial fall risk" 4.00-fold (1.93-8.3; p < 0.001) and in "high fall risk" 3.00-fold (0.97-9.22; nonsignificant) higher risk of falls compared to the "low fall risk" group. Performance in physical tests did not account for future falls. CONCLUSIONS: The KS form proved to be a feasible tool for self-administered fall risk assessment with moderate predictive ability. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02665169, date of first registration 27/01/2016.

Does long-term recreational gymnastics prevent injurious falls in older women? A prospective 20-year follow-up.

BACKGROUND: Exercise interventions focusing on balance and strength training have been shown to be effective for falls prevention. The aim of this 20-year register-based follow-up was to examine whether long-term participation in recreational female gymnastics is associated with a lower risk of medically-attended injurious falls. METHODS: Health care register data of 187 women (103 recreational gymnasts and 84 sedentary controls) from the original cohort of 243 women were assessed. The mean age (sd) at baseline was 62.8 (5.4) years and the mean follow-up time was 19.4 (2.7) years (range from 5.6 to 21.0 years). Injurious falls were scrutinized from medical records. An injurious fall was defined as an event in which falling was mentioned as a reason for making contact with health-care professionals. Negative binomial regression was used to estimate incidence rate ratios (IRR) for injurious falls, and Cox-regression models for calculating hazard ratios (HR) for injured fallers with the control group as reference. RESULTS: Recreational gymnasts had about 30% less injurious falls compared to controls, the mean IRR (95% CI) being 0.71 (0.51 to 0.96). The HR for injured fallers was 0.73 (0.52 to 1.02) favoring the recreational gymnasts. There were no statistically significant between-group differences for fractures. CONCLUSIONS: Long-term recreational gymnastics appears to reduce the risk of injurious falls in old age.

Effects of Vitamin D and Exercise on the Wellbeing of Older Community-Dwelling Women: A Randomized Controlled Trial.

BACKGROUND: Evidence for the effects of exercise and vitamin D supplementation on quality of life (QoL), fear of falling (FoF) and mental wellbeing in older adults is conflicting. OBJECTIVE: To study the effects of vitamin D supplementation and multimodal group exercise on psychosocial functions of wellbeing, including QoL, mental wellbeing and FoF. METHOD: This is a 2-year, double-blind, placebo-controlled vitamin D and open exercise intervention trial with 409 older Finnish women (70-80 years of age) randomized to 4 treatment arms: (1) placebo without exercise, (2) vitamin D (800 IU/day) without exercise, (3) placebo and exercise, and (4) vitamin D (800 IU/day) with exercise. Exercisers participated in group exercise twice per week for 12 months and once per week for the subsequent 12 months, plus home exercises. RESULTS: When comparing with the placebo without exercise group, there were no statistically significant differences between groups receiving either vitamin D, exercise or both treatments for changes in QoL or mental wellbeing (although a slight decline was seen in mental wellbeing in those receiving vitamin D only, p = 0.044). The initial slight reduction in FoF was significant in all intervention groups compared with controls (p < 0.05), but this was only temporary. CONCLUSION: Neither vitamin D nor exercise contributes to better QoL, FoF or mental wellbeing in community-dwelling healthy older women with sufficient vitamin D levels.

Combined resistance and balance-jumping exercise reduces older women's injurious falls and fractures: 5-year follow-up study.

BACKGROUND AND OBJECTIVE: previously, a randomised controlled exercise intervention study (RCT) showed that combined resistance and balance-jumping training (COMB) improved physical functioning and bone strength. The purpose of this follow-up study was to assess whether this exercise intervention had long-lasting effects in reducing injurious falls and fractures. DESIGN: five-year health-care register-based follow-up study after a 1-year, four-arm RCT. SETTING: community-dwelling older women in Finland. SUBJECTS: one hundred and forty-five of the original 149 RCT participants; women aged 70-78 years at the beginning. METHODS: participants' health-care visits were collected from computerised patient register. An injurious fall was defined as an event in which the subject contacted the health-care professionals or was taken to a hospital, due to a fall. The rate of injured fallers was assessed by Cox proportional hazards model (hazard ratio, HR), and the rate of injurious falls and fractures by Poisson regression (risk ratio, RR). RESULTS: eighty-one injurious falls including 26 fractures occurred during the follow-up. The rate of injured fallers was 62% lower in COMB group compared with the controls (HR 0.38, 95% CI 0.17 to 0.85). In addition, COMB group had 51% less injurious falls (RR 0.49, 95% CI 0.25 to 0.98) and 74% less fractures (RR 0.26, 95% CI 0.07 to 0.97). CONCLUSIONS: home-dwelling older women who participated in a 12-month intensive multi-component exercise training showed a reduced incidence for injurious falls during 5-year post-intervention period. Reduction in fractures was also evident. These long-term effects need to be confirmed in future studies.

Concern about falling in older women with a history of falls: associations with health, functional ability, physical activity and quality of life.

BACKGROUND: Fear of falling has been linked to activity restriction, functional decline, decreased quality of life and increased risk of falling. Factors that distinguish persons with a high concern about falling from those with low concern have not been systematically studied. OBJECTIVE: This study aimed to expose potential health-related, functional and psychosocial factors that correlate with fear of falling among independently living older women who had fallen in the past year. METHODS: Baseline data of 409 women aged 70-80 years recruited to a randomised falls prevention trial (DEX) (NCT00986466) were used. Participants were classified according to their level of concern about falling using the Falls Efficacy Scale International (FES-I). Multinomial logistic regression analyses were performed to explore associations between health-related variables, functional performance tests, amount of physical activity, quality of life and FES-I scores. RESULTS: 68% of the participants reported a moderate to high concern (FES-I ≥ 20) about falls. Multinomial logistic regression showed that highly concerned women were significantly more likely to have poorer health and quality of life and lower functional ability. Reported difficulties in instrumental activities of daily living, balance, outdoor mobility and poorer quality of life contributed independently to a greater concern about falling. CONCLUSIONS: Concern about falling was highly prevalent in our sample of community-living older women. In particular, poor perceived general health and mobility constraints contributed independently to the difference between high and low concern of falling. Knowledge of these associations may help in developing interventions to reduce fear of falling and activity avoidance in old age.

Feasibility of whole-body vibration training in nursing home residents with low physical function: a pilot study.

BACKGROUND AND AIMS: Whole-body vibration (WBV) training may offer an efficient option to improve physical performance of nursing home residents, but the feasibility of WBV training among frail elderly who require continuous institutional care is still open. METHODS: Fifteen nursing home residents (mean age 84 years) with low physical performance (mean SPPB score 3.7) participated in this blinded, randomized controlled pilot trial. The intervention was either a 10 week, twice-a-week progressive vibration training with slight exercises done on a side-alternating device or similar sham training without vibration. Physical performance was assessed with Short Physical Performance Battery (SPPB), Timed Up and Go, walk speed and grip strength tests. RESULTS: Low 12 Hz frequency was well tolerated with mean 95 % compliance in contrast to higher 18 Hz (or 26 Hz) frequency, which was poorly (<30 %) tolerated. While treatment effects were not significant, the mean change in SPPB score was 0.4 (range from -2 to +4) in the WBV group in contrast to -0.1 (from -3 to +3) in the sham group. DISCUSSION AND CONCLUSION: Frail nursing home residents form not only a potential but also challenging target group for physical rehabilitation with WBV. Side-alternating WBV training performed at low 12 Hz frequency was found generally feasible, whereas higher frequencies appeared formidable. Nevertheless, it is possible that physical performance of some frail elderly without contraindications to WBV can be improved with this type of rapidly executable physical training.

Study protocol for prevention of falls: a randomized controlled trial of effects of vitamin D and exercise on falls prevention.

BACKGROUND: Falls are the leading cause of unintentional injury and injury-related death among older people. In addition to physical activity, vitamin D also may affect balance and neuromuscular function. Low serum 25-hydroksivitamin D level increases the risk of bone loss, falls and fractures. Thus, an appropriate exercise program and sufficient vitamin D intake may significantly improve not only functional balance, but also balance confidence. Balance represents a complex motor skill determined by reaction time, muscle strength, and speed and coordination of movement. METHODS/DESIGN: A 2-year randomized double-blind placebo-controlled vitamin D and open exercise trial of 409 home-dwelling women 70 to 80 years of age comprising four study arms: 1) exercise + vitamin D (800 IU/d), 2) exercise + placebo, 3) no exercise + vitamin D (800 IU/d), 4) no exercise + placebo. In addition to monthly fall diaries, general health status, life style, bone health, physical functioning, and vitamin D metabolism will be assessed. The primary outcomes are the rate of falls and fall-related injuries. Secondary outcomes include changes in neuromuscular functioning (e.g. body balance, muscle strength), ADL- and mobility functions, bone density and structure, cardiovascular risk factors, quality of life and fear of falling. DISCUSSION: The successful completion of this trial will provide evidence on the effectiveness of exercise and vitamin D for falls reduction. TRIAL REGISTRATION: ClinicalTrial.gov -register (NCT00986466).

Effects of exercise on health-related quality of life and fear of falling in home-dwelling older women.

This randomized, controlled trial evaluated the effects of exercise on health-related quality of life (HRQoL) and fear of falling (FoF) among 149 home-dwelling older women. The 12-mo exercise program was intended to reduce the risk of falls and fractures. HRQoL was assessed by the RAND-36 Survey, and FoF, with a visual analog scale, at baseline, 12 mo, and 24 mo. On all RAND-36 scales, the scores indicated better health and well-being. The exercise had hardly any effect on HRQoL; only the general health score improved slightly compared with controls at 12 mo (p = .019), but this gain was lost at 24 mo. FoF decreased in both groups during the intervention with no between-groups difference at 12 or 24 mo. In conclusion, despite beneficial physiological changes, the exercise intervention showed rather limited effects on HRQoL and FoF among relatively high-functioning older women. This modest result may be partly because of insufficient responsiveness of the assessment instruments used.

Bone Mass and Strength and Fall-Related Fractures in Older Age.

INTRODUCTION: Low bone mineral density is a risk factor for fractures. The aim of this follow-up study was to assess the association of various bone properties with fall-related fractures. MATERIALS AND METHODS: 187 healthy women aged 55 to 83 years at baseline who were either physically active or inactive were followed for 20 years. They were divided into two groups by whether or not they sustained fall-related fractures: fracture group (F) and nonfracture group (NF). At baseline, several bone properties were measured with DXA and pQCT, and their physical performance was also assessed. RESULTS: During the follow-up, 120 women had no fall-related fractures, while 67 (38%) sustained at least one fall with fracture. NF group had about 4 to 11% greater BMD at the femoral neck and distal radius; the mean differences (95% CI) were 4.5 (0.3 to 8.6) % and 11.1 (6.3 to 16.1) %, respectively. NF group also had stronger bone structure at the tibia, the mean difference in BMC at the distal tibia was 6.0 (2.2 to 9.7) %, and at the tibial shaft 3.6 (0.4 to 6.8) %. However, there was no mean difference in physical performance. CONCLUSIONS: Low bone properties contribute to the risk of fracture if a person falls. Therefore, in the prevention of fragility fractures, it is essential to focus on improving bone mass, density, and strength during the lifetime. Reduction of falls by improving physical performance, balance, mobility, and muscle power is equally important.

Counselling for physical activity, life-space mobility and falls prevention in old age (COSMOS): protocol of a randomised controlled trial.

INTRODUCTION: The most promising way to promote active life years in old age is to promote regular participation in physical activity (PA). Maintaining lower extremity muscle function with good balance has been associated with fewer falls and the need of help from others. This article describes the design and intervention of a randomised controlled trial (RCT) investigating the effectiveness of a health and PA counselling programme on life-space mobility and falls rates in community-dwelling older adults at the Health Kiosk and/or Service Centre. METHODS AND ANALYSIS: Community-dwelling men and women (n=450) aged 65 years and over with early phase mobility limitation will be recruited to a 24-month RCT with a 24-month follow-up. Participants will be randomly allocated into either a health and PA counselling group (intervention) or relaxation group (control intervention). All participants will receive five group specific face-to-face counselling sessions and 11 phone calls. The counselling intervention will include individualised health counselling, strength and balance training, and guidance to regular PA. The control group will receive relaxation exercises. Outcomes will be assessed at baseline, 12, 24 and 48 months. Primary outcomes are average life-space mobility score and falls rates. Life-space mobility will be assessed by a validated questionnaire. Falls rates will be recorded from fall diaries. Secondary outcomes are data on fall-induced injuries and living arrangements, number of fallers, fracture risk, mean level of PA, physical performance, quality of life, mood, cognition, balance confidence and fear of falling. Data will be analysed using the intention-to-treat principle. Cost-effectiveness of the programme will be analysed. Ancillary analyses are planned in participants with greater adherence. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Ethics Committee of the Tampere University Hospital (R15160). Outcomes will be disseminated through publication in peer-reviewed journals and presentations at international conferences. TRIAL REGISTRATION: ISRCTN65406039; Pre-results.

Exercise Training in Treatment and Rehabilitation of Hip Osteoarthritis: A 12-Week Pilot Trial.

Introduction. Osteoarthritis (OA) of the hip is one of the major causes of pain and disability in the older population. Although exercise is an effective treatment for knee OA, there is lack of evidence regarding hip OA. The aim of this trial was to test the safety and feasibility of a specifically designed exercise program in relieving hip pain and improving function in hip OA participants and to evaluate various methods to measure changes in their physical functioning. Materials and Methods. 13 women aged ≥ 65 years with hip OA were recruited in this 12-week pilot study. Results. Pain declined significantly over 30% from baseline, and joint function and health-related quality of life improved slightly. Objective assessment of physical functioning showed statistically significant improvement in the maximal isometric leg extensor strength by 20% and in the hip extension range of motion by 30%. Conclusions. The exercise program was found to be safe and feasible. The present evidence indicates that the exercise program is effective in the short term. However, adequate powered RCTs are needed to determine effects of long-term exercise therapy on pain and progression of hip OA.

A 2-Year Follow-Up After a 2-Year RCT with Vitamin D and Exercise: Effects on Falls, Injurious Falls and Physical Functioning Among Older Women.

BACKGROUND: Both exercise and vitamin D are recommended means to prevent falls among older adults, but their combined effects on fall-induced injuries are scarcely studied. METHODS: A 2-year follow-up of a previous 2-year randomized controlled trial with vitamin D and exercise (Ex) of 409 older home-dwelling women using a factorial 2 × 2 design (D-Ex-, D+Ex-, D-Ex+, D+Ex+). Besides monthly fall diaries, femoral neck bone mineral density (fn-BMD), and physical functioning were assessed at 1 and 2 years after the intervention. RESULTS: After the intervention, S-25OHD concentrations declined to baseline levels in both supplement groups. The groups did not differ for change in fn-BMD or physical functioning, except for leg extensor muscle strength, which remained about 10% greater in the exercise groups compared with the reference group (D-Ex-). There were no between-group differences in the rate of all falls, but medically attended injurious falls reduced in D+Ex- and D-Ex+ groups compared with D-Ex-. However, all former treatment groups had less medically attended injured fallers, HRs (95% CI) being 0.62 (0.39-1.00) for D+Ex-, 0.46 (0.28-0.76) for D-Ex+, and 0.55 (0.34-0.88) for D+Ex+, compared with D-Ex-. CONCLUSIONS: Exercise-induced benefits in physical functioning partly remained 2 years after cessation of supervised training. Although there was no difference in the rate of all falls, former exercise groups continued to have lower rate of medically attended injured fallers compared with referents even 2 years after the intervention. Vitamin D without exercise was associated with less injurious falls with no difference in physical functioning.

Effects of long-term whole-body vibration training on mobility in patients with multiple sclerosis: A meta-analysis of randomized controlled trials.

BACKGROUND: This meta-analysis evaluated feasibility and efficacy of long-term whole-body vibration (WBV) training in improving mobility of multiple sclerosis (MS) patients. METHODS: The primary search of this meta-analysis was conducted from four electronic databases (PubMed, Sport, CINAHL and Cochrane) in order to find all relevant randomized, controlled WBV intervention trials of MS patients published between January 2000 and October 2013. The primary search was complemented by a recent (Aug 2015) PubMed search. Data on patients' characteristics and type of WBV intervention were extracted from the published reports and supplementary material. Two researchers independently assessed the methodological quality of these studies and outcomes. Standardized mean differences based on the baseline-adjusted follow-up results were calculated as indicators of the effect size (ES) of WBV training. RESULTS: Seven randomized controlled trials (RCTs) involving 250 MS patients were found. Relevant group-based data for analysis were available from 109 patients in WBV groups and from 100 control patients; 41 patients withdrew from the studies. Quality assessment revealed that the WBV training protocols were heterogeneous and the methodological quality of the studies was generally poor. We found borderline indication for improved 2-6 min walking endurance [ES=0.25 (95% CI=-0.06-0.0.55)] favoring WBV training whereas no benefits were indicated for short-distance (20m or less) walking speed or balance. CONCLUSION: This meta-analysis suggests that WBV training has potential in improving walking endurance in MS patients with low disability status. However, evidence for more severely disabled MS patients is lacking, and further well-designed, long-term RCTs with adequate sample sizes are needed.

Effects of a Multimodal Exercise Program on Physical Function, Falls, and Injuries in Older Women: A 2-Year Community-Based, Randomized Controlled Trial.

OBJECTIVES: To investigate the effects of multimodal supervised exercise on physical functioning, falls, and related injuries in older women. DESIGN: Two-year randomized controlled trial. SETTING: Tampere, Finland. PARTICIPANTS: Women aged 70 to 80 who had fallen in the previous year (n = 409). INTERVENTION: Participants were randomly assigned to an exercise or control group (ClinicalTrial.gov NCT00986466). Exercisers participated in group exercise classes twice a week for 12 months and once a week for the subsequent 12 months and home exercises. Controls maintained their current physical activity. MEASUREMENTS: Physical functioning assessed at baseline and at 6-month intervals during the intervention. Falls and related injuries monitored with fall diaries. RESULTS: Intention-to-treat analyses showed that exercise led to significant improvements in physical functioning. Leg strength differed significantly between the groups (mean change: 14.1%, 95% confidence interval (CI) = 8.0 to 20.2 in exercisers; 1.6%, 95% CI = -4.5 to 7.7 in controls; P < .001). Chair stand time also differed significantly between groups (7.4%, 95% CI 3.8 to 10.8% in exercisers; 2.4%, 95% CI = -1.6 to 6.2) in controls; P = .02). Between-group differences were significant for fast walking speed (P = .003) and probability of completing the backward walking test (P < .001), favoring exercisers. Timed Up-and-Go and grip strength did not differ between groups. There was no difference in the total falls incidence rate ratio (IRR = 1.0, 95% CI = 0.79 to 1.26), but exercisers were less likely to have medically attended injurious falls (IRR = 0.45, 95% CI = 0.27 to 0.78; P = .004). CONCLUSION: Twenty-four months of multimodal exercise enhanced physical functioning in women aged 70 to 80 with a history of falls. Although the total number of falls was not lower than in controls, the rate of medically attended injurious falls was more than 50% lower.

Exercise and vitamin D in fall prevention among older women: a randomized clinical trial.

IMPORTANCE: While vitamin D supplementation and exercise are recommended for prevention of falls for older people, results regarding these 2 factors are contradictory. OBJECTIVE: To determine the effectiveness of targeted exercise training and vitamin D supplementation in reducing falls and injurious falls among older women. DESIGN, SETTING, AND PARTICIPANTS: A 2-year randomized, double-blind, placebo-controlled vitamin D and open exercise trial conducted between April 2010 and March 2013 in Tampere, Finland. Participants were 409 home-dwelling women 70 to 80 years old. The main inclusion criteria were at least 1 fall during the previous year, no use of vitamin D supplements, and no contraindication to exercise. INTERVENTIONS: Four study groups, including placebo without exercise, vitamin D (800 IU/d) without exercise, placebo and exercise, and vitamin D (800 IU/d) and exercise. MAIN OUTCOMES AND MEASURES: The primary outcome was monthly reported falls. Injurious falls and the number of fallers and injured fallers were reported as secondary outcomes. In addition, bone density, physical functioning (muscle strength, balance, and mobility), and vitamin D metabolism were assessed. RESULTS: Intent-to-treat analyses showed that neither vitamin D nor exercise reduced falls. Fall rates per 100 person-years were 118.2, 132.1, 120.7, and 113.1 in the placebo without exercise, vitamin D without exercise, placebo and exercise, and vitamin D and exercise study groups, respectively; however, injurious fall rates were 13.2, 12.9, 6.5, and 5.0, respectively. Hazard ratios for injured fallers were significantly lower among exercisers with vitamin D (0.38; 95% CI, 0.17-0.83) and without vitamin D (0.47; 95% CI, 0.23-0.99). Vitamin D maintained femoral neck bone mineral density and increased tibial trabecular density slightly. However, only exercise improved muscle strength and balance. Vitamin D did not enhance exercise effects on physical functioning. CONCLUSIONS AND RELEVANCE: The rate of injurious falls and injured fallers more than halved with strength and balance training in home-dwelling older women, while neither exercise nor vitamin D affected the rate of falls. Exercise improved physical functioning. Future research is needed to determine the role of vitamin D in the enhancement of strength, balance, and mobility. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00986466.

Improved femoral neck BMD in older Finnish women between 2002 and 2010.

PURPOSE: The number of hip fractures among Finns over 50-years of age rose constantly between 1970 and 1997, but since then, there has been a nationwide decline in incidence of hip fractures. One possible explanation, although not the only one, for the declining fracture rates, could be improved bone mineral density (BMD). The aim of this study was to evaluate differences in femoral neck BMD between older Finnish women born about a decade apart. METHODS: We compared the baseline data of two population-based samples of home-dwelling 70-80-year-old women who were initially recruited in exercise intervention studies (N=216 in Cohort1, and N=389 in Cohort 2). Femoral neck BMD was measured with DXA. Between-cohort differences were evaluated with analysis of covariance using age, height, weight, and use of hormone therapy as covariates. RESULTS: The later-born Cohort 2 was somewhat older and taller than Cohort 1. Adjusted mean difference (95% CI) in femoral neck BMD between the cohorts was 0.043g/cm(2) (0.023-0.064) corresponding the mean difference of 0.36 (0.19-0.53) in T-score in favor of Cohort 2. CONCLUSIONS: Despite several factors that basically could have indicated lower mean BMD in Cohort 2, the finding was the opposite. This suggests that the mean femoral neck BMD has increased substantially among older Finnish women within a decade, but primary reason for this improvement remains unclear, but improved social and economic resources may have at least partly accounted for this favorable phenomenon.

Physical therapy approaches to reduce fall and fracture risk among older adults.

Falls and fall-related injuries, such as fractures, are a growing problem among older adults, often causing longstanding pain, functional impairments, reduced quality of life and excess health-care costs and mortality. These problems have led to a variety of single component or multicomponent intervention strategies to prevent falls and subsequent injuries. The most effective physical therapy approach for the prevention of falls and fractures in community-dwelling older adults is regular multicomponent exercise; a combination of balance and strength training has shown the most success. Home-hazard assessment and modification, as well as assistive devices, such as canes and walkers, might be useful for older people at a high risk of falls. Hip protectors are effective in nursing home residents and potentially among other high-risk individuals. In addition, use of anti-slip shoe devices in icy conditions seems beneficial for older people walking outdoors. To be effective, multifactorial preventive programs should include an exercise component accompanied by individually tailored measures focused on high-risk populations. In this Review, we focus on evidence-based physical therapy approaches, including exercise, vibration training and improvements of safety at home and during periods of mobility. Additionally, the benefits of multifaceted interventions, which include risk factor assessment, dietary supplements, elements of physical therapy and exercise, are addressed.