Our column on research that's relevant to physiotherapists and the latest clinical findings
Falls occur in a third of community-dwelling individuals who are more than 65 years of age. Falls can cause serious injuries, and the rate of injuries increases as individuals get older. The aim of this review was to assess the effects of exercise interventions for preventing falls in older people living in the community when compared with a usual care or attention control.
Methods
Exercise interventions reduce the rate of falls by 23% in community dwelling individuals aged over 60 years of age compared to control
The review included randomised controlled trials that evaluated the effects of exercise interventions compared to usual care or attention control in community-dwelling individuals 60 years of age and older. Exercise programmes were classified using the Prevention of Falls Network Europe (ProFaNE) taxonomy (balance and functional exercises, resistance exercises, flexibility, three-dimensional exercise, walking programmes, endurance, other). The review defined community-dwelling individuals as those living at home or in residences where they do not provide residential health-related care or rehabilitation. The review excluded trials that only included individuals with clinical conditions known to increase the risk of falls. The main outcome for this review was the rate of falls. Risk of bias for all eligible trials was assessed using Cochrane’s risk of bias tool. The certainty of evidence was judged using the Grading of Recommendations, Assessment, Development and Evaluation approach.
Results
The review included 108 randomised controlled trials, conducted in 25 countries, involving 23,407 participants. 77% of participants were women and the average age was 76 years. Overall, there was high-certainty evidence that exercise reduced the rate of falls by 23% when compared to control (rate ratio 0.77, 95% confidence interval (CI) 0.71 to 0.83, 59 trials, 12,981 participants). Certain exercise types reduced the rate of falls more than others when compared to control, there was: high-certainty evidence for interventions that mainly focussed on balance and functional tasks (rate ratio 0.76, 95% CI 0.70 to 0.81, 39 trials, 7,920 participants); moderate-certainty evidence for balance and functional exercises with resistance exercises (rate ratio 0.66, 95% CI 0.50 to 0.88, 11 trials, 1,374 participants); and low-certainty evidence for three-dimensional exercise (Tai Chi or similar) (rate ratio 0.81, 95% CI 0.67 to 0.99, 7 trials, 2,655 participants).
Subgroup analyses showed that there was little difference in the effect of exercise on the rate of falling when:
- Trials included participants at increased baseline risk of falling compared to trials that did not (rate ratio 0.80, 95% CI 0.72 to 0.88 versus 0.74, 95% CI 0.65 to 0.84)
- Trials that only included participants 75 years of age and older compared to trials of participants less than 75 years of age (rate ratio 0.83, 95% CI 0.72 to 0.97 versus 0.75, 95% CI 0.69 to 0.82)
- Trials where the exercise intervention was delivered in a group setting compared to individually delivered exercise (rate ratio 0.76, 95% CI 0.69 to 0.85 versus 0.79, 95% CI 0.71 to 0.88).
Exercise interventions led by health professionals (such as a physiotherapist) resulted in a greater reduction in the rate of falls compared to those led by non-health professionals (such as a trained fitness leader), although both still resulted in a reduction in rate of falls (rate ratio 0.69, 95% CI 0.61 to 0.79 versus 0.82, 95% CI 0.75 to 0.90).
Implications
Falls occur in 1/3 of over 65's living in the community
There is high-certainty evidence that exercise interventions reduce the rate of falls by 23 per cent in community dwelling individuals aged over 60 years of age compared to control.
If there were 850 falls in 1,000 people followed over one year, exercise would result in 195 fewer falls (95% CI 144 to 246). Exercise interventions that primarily focus on balance and functional activities can reduce the rate of falls. Exercise led by health professionals results in a greater reduction in the rate of falls.
Expert view: Annabelle Long AGILE Research Officer
The findings from this updated review by Sherrington et al has several implications for current clinical practice.
It is important that, when designing exercise programmes for older people living in the community, we ensure we include balance and functional exercises as a minimum. Although resistance exercises and Tai Chi have been evidenced to help in the reduction of falls, the evidence is less robust when these are done individually as opposed to in combination with balance and function exercises.
Exercise programmes were shown to be effective whether they were delivered individually or in a group. In the current climate of cost savings, it is worth considering delivering exercise in a group setting rather than on an individual basis*
A greater reduction in the rate of falls was observed when the exercise intervention was delivered by a health professional (usually a physiotherapist) rather than a trained instructor, highlighting the importance of the role of the exercise professional who is leading the programme.
Finally, the findings from the review showed little difference in the rate of falls whether participants were at risk of falling or not prior to taking part, giving weight to the potential importance of primary falls prevention in community settings.
PEDro
This evidence summary was provided by PEDro. PEDro is the Physiotherapy Evidence Database, a free database of over 46,000 randomised trials, systematic reviews and clinical practice guidelines in physiotherapy.
An infographic relating to this evidence summary can be found in PEDro’s February newsletter.
* In line with current government advice, group classes must not be delivered physically face-to-face at this time and alternative methods such as online and web-based delivery must be considered.
Citations
Sherrington C et al. Exercise for preventing falls in older people living in the community: an abridged Cochrane systematic review. Br J Sports Med 2019 Dec 2:Epub ahead of print.The Sherrington et al review is the focus of the second PEDro World-Wide Journal Club, which aims to encourage the global physiotherapy community to read trials, reviews and guidelines that have important implications for clinical practice. Visit PEDro’s World-Wide Journal Club page for information about getting involved.
Number of subscribers: 3
Log in to comment and read comments that have been added