|Exercise in preventing falls and fall related injuries in older people: a review of randomised controlled trials
|Gardner M M, Robertson M C, Campbell A J
To assess the effectiveness of exercise programmes in preventing falls, and/or lowering the risk of falls and fall-related injuries, in older people.
The following sources were searched for articles published in the English language: MEDLINE from 1990 to 1999, PsycLIT from 1991 to 1999, Current Contents from 1995 to 1999, CINAHL from 1982 to 1999, and the ISI Web of Science from 1990 to 1999. The search terms used were: 'controlled trials', 'public health', 'health promotion', 'elderly', 'old', 'exercise', 'physical activity', 'falls', 'falls injuries', 'fall prevention', 'costs' and 'cost effectiveness'.
Study designs of evaluations included in the review
Controlled clinical trials were eligible.
Specific interventions included in the review
Interventions based on exercise only, or included an exercise component, and provided details on exercise type, frequency and duration were eligible. Exercise components included: stand-up and step-down procedure; exercise sessions with physical therapist; exercise classes; t'ai chi; computerised balance training; strength training using weights machine; endurance training using stationary bicycles; combination of strength and endurance training; and strength and balance retraining exercise, as prescribed and modified by a physiotherapist. Exercise sessions included one-to-one and group activities, sessions conducted both under supervision and self-supervised, and sessions conducted at centres and at home. Cointerventions included home visits, phone calls encouraging continuance of activities, and calcium supplements. Control interventions included cognitive behavioural group sessions, discussion session, health promotion and safety education, one-to-one friendly visits, instruction to maintain usual activity levels, social visits by nurse and usual carer, withdrawal of psychotropic medication, continuation of usual medication, and no active intervention. Duration of interventions ranged from 15 weeks to 2 years.
Participants included in the review
Studies in which participants were aged 60 years or over were eligible. Actual participants included men and women with the following characteristics: frail long-stay nursing home residents; people aged 85 years with at least mild deficits in strength and balance; and those taking psychotropic medication. All but one study targeted community-dwelling rather than institutionalised people.
Outcomes assessed in the review
Studies assessing the prevention of falls and/or fall-related injuries were eligible. In addition, the review evaluated time between falls, adverse effects, costs and cost-effectiveness of interventions.
How were decisions on the relevance of primary studies made?
The authors do not state how the papers were selected for the review, or how many of the reviewers performed the selection.
Assessment of study quality
Validity was not formally assessed, although issues such as randomisation and blinding were considered.
The authors do not state how the data were extracted for the review, or how many of the reviewers performed the data extraction. The following data were extracted: study design; eligible population; population agreeing to be randomised; age distribution; setting; inclusion and exclusion criteria; generalisability; use of blinding; details of intervention, cointerventions or contamination; measurement of outcomes; numbers lost to follow-up; evidence of intervention effects; level of evidence; costs of the intervention; and effect of health care costs.
Methods of synthesis
How were the studies combined?
The studies were classified as 'exercise as a separate intervention' or 'multiple interventions trials with an exercise component', and were combined in a narrative review.
How were differences between studies investigated?
Differences between the studies were discussed.
Results of the review
Eleven randomised controlled trials (RCTs) were included (4,933 participants).
A wide variety of exercise interventions were examined with different exercise frequencies, intensities and duration periods. Differences were observed in the definition of a 'fall', and in the methods of measuring falls.
Overall, 5 trials showed a significant reduction in the rate of falls or the risk of falling in the exercise group using strength and balance retraining, endurance training or t'ai chi.
Exercise as a separate intervention (8 RCTs): 4 RCTs reported a statistically-significant benefit from the exercise intervention.
Multiple interventions trials with an exercise component (3 RCTs): 1 RCT reported a statistically-significant benefit from the exercise intervention.
Adverse events (4 RCTs): 6.5% of participants reported self-limiting musculoskeletal symptoms in one home-based programme, whilst 7% reported moderate muscle soreness in another study. In the latter study, researchers blinded to the intervention group found no difference in rates of severe soreness, bruising or fatigue between the intervention and control groups.
Three studies reported costs of the intervention ranging from US$891 to US$1,220 per intervention participant. One RCT reported the cost effectiveness of a home-based multifactorial intervention as US$1,947 per fall prevented, resulting in a cost-saving of US$12,392 in medical care. Costs were lower for the intervention group than the control, and the intervention was reported to be most cost-effective for those at high risk.
Exercise is effective in lowering the risk of falls in selected groups and should form part of fall prevention programmes. Lowering fall-related injuries will reduce health care costs, but there is little information available on the costs associated with programme replication or the cost-effectiveness of exercise programmes aimed at preventing falls in older people.
The aims were stated and inclusion criteria were defined in terms of study design, participants, intervention and outcome. Several relevant databases were searched, though limiting the included studies to those published in the English language may have resulted in the omission of other relevant articles. No attempt was made to locate unpublished material, thus raising the possibility of publication bias. Validity was not formally assessed, but some aspects of validity were considered, such as randomisation and blinding. Relevant information on the included studies was either presented in tabular format or described in the text. No details were given of methods used to select studies, assess validity or extract data. Given the differences between studies a narrative review was appropriate. Potential sources of heterogeneity in the outcome measures were considered in the discussion.
5 out of 12 studies reported benefit from exercise. Another 4 reported no significant difference. The level of the evidence on which the authors' conclusions were based would have been strengthened by including a discussion of results with respect to a formal validity assessment.
Implications of the review for practice and research
Practice: The authors state that exercise is effective in lowering the risk of falls in selected groups and should form part of fall prevention programmes. In addition, exercise programmes must be regular and sustainable to be effective.
Research: The authors state that more trials are required to determine the exercise type, frequency, duration and intensity that are most effective in lowering the risk of falls in different groups of older people.
Accident Rehabilitation and Compensation Insurance Corporation of New Zealand; Trustbank Otago Community Trust Medical Research Fellowship.
Gardner M M, Robertson M C, Campbell A J. Exercise in preventing falls and fall related injuries in older people: a review of randomised controlled trials. British Journal of Sports Medicine 2000; 34(1): 7-17
Subject indexing assigned by NLM
Accidental Falls /economics /prevention & Aged; Aged, 80 and over; Cost-Benefit Analysis; Exercise; Female; Humans; Male; Middle Aged; New Zealand; Randomized Controlled Trials as Topic; Wounds and Injuries /economics /prevention & control; control /therapy
Date bibliographic record published
Date abstract record published
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.