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Fairhall N1, Sherrington C1, Wallbank G1, Tiedemann A1, Michaleff Z1, Howard K2,3, Clemson L4, Hopewell S5, Lamb S5
1University of Sydney, Institute of Musculoskeletal Health, Sydney, Australia, 2Sydney School of Public Health, Sydney, Australia, 3Menzies Centre for Health Policy, Sydney, Australia, 4University of Sydney, Faculty of Health Sciences, Sydney, Australia, 5University of Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, United Kingdom
Background: More than one third of community-dwelling people aged over 65 years fall each year. Exercise that targets balance, gait and muscle strength has previously been found to prevent falls in this population. The best type of exercise to prevent falls has not been established.
Purpose: i) To evaluate the effect of exercise interventions for preventing falls in community-dwelling older people; ii) To establish the effects of different types of exercise on fall prevention.
Methods: Cochrane Collaboration Systematic Review with meta-analysis. We searched six databases to May 2018. We included randomised controlled trials that evaluated the effects of any form of exercise as a single intervention on falls in people aged 60+ years living in the community. We classified exercise programmes in the included trials into six categories using the PRevention of Falls Network Europe (PRoFaNE) guidelines. Rate and risk of falling were calculated and we pooled data where appropriate.
Results: This review includes 108 randomised trials with 23,407participants, conducted in 25 countries. Overall, the risk of bias in the included trials was low to moderate. Exercise reduced the rate of falls by 23% (Rate Ratio 0.77, 95% CI 0.71 to 0.83, p 0.001, I2 56%, 59 trials) compared to control. Exercise also reduced the number of people who fell by 15% (Risk Ratio 0.85, 95% CI 0.8 to 0.89, p=0.02, I227%, 62 trials), reduced the number of fall-related fractures by 27% (Risk Ratio 0.73, 95% CI 0.56 to 0.95, p=0.02, I20%, 10 trials), and reduced the number of falls requiring medical attention by 39% (Risk Ratio 0.61, 95% CI 0.47 to 0.80, p 0.001, I24%, 5 trials). There was no significant effect on number of fall-related hospitalisations or quality of life.
Three types of exercise reduced rate of falls: balance and functional exercises (Rate Ratio 0.76, 95% CI 0.70 to 0.81), Tai Chi (Rate Ratio 0.81, 95% CI 0.67 to 0.99), and a combination of multiple exercise types (primarily balance and functional exercise plus resistance training) (Rate Ratio 0.66, 95% CI 0.50-0.88). There was no statistically significant effect on falls from programmes involving only resistance exercises, dance or walking.
Pre-specified sub-group analyses revealed a greater reduction in fall rate from balance and functional exercises in trials where interventions were delivered by a health professional than in trials where the interventions were delivered by trained instructors who were not health professionals (Chi2= 6.97, p 0.001, I2=86%).
Conclusion(s): This review provides moderate to high quality evidence that well-designed exercise programmes can prevent falls. Effective programmes primarily involve balance and functional exercises, Tai Chi, or incorporate multiple exercise categories. Future work should use adequately large trials to investigate the relative impact of different exercise programmes, and should evaluate the effectiveness of fall prevention programmes in emerging economies.
Implications: The results of this review may inform guidelines for fall prevention. Further research is required to establish strategies to enhance implementation of effective exercise-based fall prevention interventions into care of older people in both clinical and community settings.
Keywords: Fall, exercise, ageing
Funding acknowledgements: National Institute for Health Research; Australian National Health and Medical Research Council; National Institute for Health and Care Excellence.
Purpose: i) To evaluate the effect of exercise interventions for preventing falls in community-dwelling older people; ii) To establish the effects of different types of exercise on fall prevention.
Methods: Cochrane Collaboration Systematic Review with meta-analysis. We searched six databases to May 2018. We included randomised controlled trials that evaluated the effects of any form of exercise as a single intervention on falls in people aged 60+ years living in the community. We classified exercise programmes in the included trials into six categories using the PRevention of Falls Network Europe (PRoFaNE) guidelines. Rate and risk of falling were calculated and we pooled data where appropriate.
Results: This review includes 108 randomised trials with 23,407participants, conducted in 25 countries. Overall, the risk of bias in the included trials was low to moderate. Exercise reduced the rate of falls by 23% (Rate Ratio 0.77, 95% CI 0.71 to 0.83, p 0.001, I2 56%, 59 trials) compared to control. Exercise also reduced the number of people who fell by 15% (Risk Ratio 0.85, 95% CI 0.8 to 0.89, p=0.02, I227%, 62 trials), reduced the number of fall-related fractures by 27% (Risk Ratio 0.73, 95% CI 0.56 to 0.95, p=0.02, I20%, 10 trials), and reduced the number of falls requiring medical attention by 39% (Risk Ratio 0.61, 95% CI 0.47 to 0.80, p 0.001, I24%, 5 trials). There was no significant effect on number of fall-related hospitalisations or quality of life.
Three types of exercise reduced rate of falls: balance and functional exercises (Rate Ratio 0.76, 95% CI 0.70 to 0.81), Tai Chi (Rate Ratio 0.81, 95% CI 0.67 to 0.99), and a combination of multiple exercise types (primarily balance and functional exercise plus resistance training) (Rate Ratio 0.66, 95% CI 0.50-0.88). There was no statistically significant effect on falls from programmes involving only resistance exercises, dance or walking.
Pre-specified sub-group analyses revealed a greater reduction in fall rate from balance and functional exercises in trials where interventions were delivered by a health professional than in trials where the interventions were delivered by trained instructors who were not health professionals (Chi2= 6.97, p 0.001, I2=86%).
Conclusion(s): This review provides moderate to high quality evidence that well-designed exercise programmes can prevent falls. Effective programmes primarily involve balance and functional exercises, Tai Chi, or incorporate multiple exercise categories. Future work should use adequately large trials to investigate the relative impact of different exercise programmes, and should evaluate the effectiveness of fall prevention programmes in emerging economies.
Implications: The results of this review may inform guidelines for fall prevention. Further research is required to establish strategies to enhance implementation of effective exercise-based fall prevention interventions into care of older people in both clinical and community settings.
Keywords: Fall, exercise, ageing
Funding acknowledgements: National Institute for Health Research; Australian National Health and Medical Research Council; National Institute for Health and Care Excellence.
Topic: Older people; Health promotion & wellbeing/healthy ageing
Ethics approval required: No
Institution: N/A
Ethics committee: N/A
Reason not required: Systematic review
All authors, affiliations and abstracts have been published as submitted.
