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  • APTA to Submit Feedback on USPSTF Draft Falls Prevention Recommendations

    The United States Preventive Services Task Force (USPSTF) issued draft recommendations for falls prevention in community-dwelling adults age 65 or older, and APTA will issue formal comments after receiving feedback from member experts from the Academy of Geriatric Physical Therapy and the Academy of Neurologic Physical Therapy.

    APTA members are encouraged to submit their own comments as well.

    Based on an evidence review, USPSTF concludes with moderate certainty that both group and supervised individual exercise can reduce risk for falls. Regular exercise should include aerobic and strengthening activities, as well as balance and gait training.

    The task force found only a small net benefit to routinely providing a multidisciplinary assessment and a customized “multifactorial” combination of interventions, such as exercise, psychological interventions, and physical therapy, among others; however, authors acknowledge that, for certain older patients with a history of falls and comorbid conditions, an “in-depth multifactorial risk assessment with comprehensive management” may be appropriate. Authors also write that vitamin D supplementation has no benefit in falls prevention.

    Want more on falls prevention? Check out the falls-related resources at PTNow, including a unilateral vestibular hypofunction clinical summary, a summary on falls risk in community-dwelling elders, an osteoporosis clinical summary, and tests and measures such as a fracture risk assessment, a clinical test of sensory interaction and balance, and a self-paced walk test. APTA also offers resources at its Balance and Falls webpage.

    Comments

    • I have submitted the following to the USPSTF as I found over the years some studies that lend support for vitamin D as a means to help possibly improve movement dysfunction and/or cognition dysfunction which can impact fall risk. So I am not yet willing to close the door on vitamin D, and share the following with the hope that experts in movement system science may be able to shed more light on this topic. There is growing evidence that vitamin D and vitamin D receptors (VDR), which are in most mammalian/human cells, play a significant role in neuromusculoskeletal functions and movement. VDRs are in many areas within the central nervous system: hippocampus, hypothalamus, substantia nigra, limbic system, cerebellum and spinal motor zones.1 Littlejohns et. al. (N=1658) found increased vitamin D deficiencies were associated with increased risks of all-cause dementia and Alzheimer disease.2 Knekt P et. al. (N=3173) found evidence of the association between low vitamin D levels and the prevalence of PD supporting previous cross-sectional studies of hypovitaminosis D in people living with PD.3 Studies that involve suppressing VDR areas in mice models have shown significantly reduced functional movement capability, incoordination, shorter stride length, abnormal swimming patterns and behavioral abnormalities.4-6 These studies and others support the cause-effect relationship between chronic vitamin D deficiency and the loss of neurons contributing to muscle weakness, slow/delayed balance reactions and postural instability, CNS disease, depression, gait disturbances and fall risk. Vitamin D is becoming a promising biomarker and treatment for various conditions. Further research of specific vitamin D pathways effecting muscle, bone and neural tissue function for determining clinical dosing parameters for reducing fall risk is still needed. Meanwhile, a substantial and growing body of evidence supports intake of over-the-counter vitamin D (600 IU per day for people age 1-70 years and 800 IU per day for people 70+ years) as a protectant against fractures, movement dyscontrol (e.g. muscle weakness, sensory loss, incoordination, posture control impairment, falls, hormonal imbalances, blood flow abnormalities, neuromusculoskeletal structural atrophies), pain, cognitive decline, depression and brain-based diseases (e.g. AD, PD).7-15. 1. Eyles DW, Smith S, Kinobe R, Hewison M, McGrath JJ. Distribution of the Vitamin D receptor and 1 alpha-hydroxylase in human brain. Journal of Chemical Neuroanatomy. 2005;29(1):21-30. DOI: 10.1016/j.jchemneu.2004.08.006. 2. Littlejohns TJ, Henley WE, Lang IA, Annweiler C, Beauchet O, Chaves PHM, et. al. Vitamin D and the risk of dementia and Alzheimer disease. Neurology. 2014;83:10 920-928. 3. Knekt P, Kilkkinen A, Rissanen H, Marniemi J, Sääksjärvi K, Heliövaara M. Serum vitamin D and the risk of Parkinson’s disease. Archives of neurology. 2010;67(7):808-811. doi:10.1001/archneurol.2010.120. 4. Kalueff AV, Lou YR, Laaksi I, Tuohimaa P. Impaired motor performance in mice lacking neurosteroid vitamin D receptors. Brain Res Bull. 2004;64:25–29. 5. Burne TH, Johnston AN, McGrath JJ, Mackay-Sim A. Swimming behaviour and post-swimming activity in vitamin D receptor knockout mice. Brain Res Bull. 2006;69:74–78. 6. Girgis CM, Mokbel N, Cha KM, et al. The Vitamin D Receptor (VDR) Is Expressed in Skeletal Muscle of Male Mice and Modulates 25-Hydroxyvitamin D (25OHD) Uptake in Myofibers. Endocrinology. 2014;155(9):3227-3237. doi:10.1210/en.2014-1016. 7. Annweiler C, Allali G, Allain P, et al. Vitamin D and cognitive performance in adults: a systematic review. Eur J Neurol. 2009; 16:1083–1089. 8. Pojednic RM, Ceglia L. The Emerging Biomolecular Role of Vitamin D in Skeletal Muscle. Exercise and sport sciences reviews. 2014;42(2):76-81. doi:10.1249/JES.0000000000000013. 9. Annweiler C, Montero-Odasso M, Schott AM, Berrut G, Fantino B, Beauchet O. Fall prevention and vitamin D in the elderly: an overview of the key role of the non-bone effects. J Neuroeng Rehabil. 2010; 7:50. 10. Annweiler C, Beauchet O. High-dose vitamin D repletion-related falls and fractures: an uncontrolled mobility gain? Biofactors. 2010; 36:407. 11. Annweiler C, Schott AM, Allali G, et al. Association of vitamin D deficiency with cognitive impairment in older women: cross-sectional study. Neurology. 2010; 74:27–32. 12. Annweiler C, Schott AM, Rolland Y, Blain H, Herrmann FR, Beauchet O. Dietary intake of vitamin D and cognition in older women: a large population-based study. Neurology. 2010;75:1810–1816. 13. Sanders KM, Stuart AL, Williamson EJ, Simpson JA, Kotowicz MA, Young D, et al. Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. JAMA. 2010; 303:1815–1822. 14. Bischoff HA, Staehelin HB, Dick W, Akos R, Knecht M, Salis C, Nebiker M, Theiler R, Pfeifer M, Begerow B, Lew RA, Conzelmann M: Effects of vitamin D and calcium supplementation on falls: A randomized controlled trial. J Bone Miner Res. 2003;18: 343–351. 15. Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC, Staehelin HB, Bazemore MG, Zee RY, Wong JB: Effect of vitamin D on falls. JAMA. 2004;291:1999 –2006.

      Posted by Lise McCarthy, PT, DPT, GCS on 10/13/2017 8:13 AM

    • The summary states: "The USPSTF recommends against vitamin D supplementation to prevent falls in community-dwelling adults age 65 years or older." This statement may mislead consumers and healthcare providers into assuming that there is no fall prevention benefit associated with Vitamin D supplementation to correct Vitamin D deficiency. Readers have to read way down to the Update of Previous USPSTF Recommendation section, which is near the end of the document, in order to be informed that "The current review excluded studies considered in the previous review that enrolled persons with vitamin D deficiency or insufficiency because, upon further consideration, vitamin D interventions in these populations would be considered treatment rather than prevention." This section goes on to state: With this revised scope of review, as well as newer evidence from trials reporting no benefit, the USPSTF found that vitamin D supplementation has no benefit in falls prevention in community-dwelling older adults not known to have vitamin D deficiency or insufficiency."

      Posted by Cindy Moore, PT, MPH, DPT on 10/13/2017 9:05 PM

    • The area on Vit D recommendation is not totally factual. The IOM research looked at dose vs falls, rather than serum levels vs falls. Serum levels must be used because of the variability in individual response to dosing. For example, age, skin color, use of sun screen, GI issues, alcohol consumption, medication use, weight all influence a person’s response to a give dose of vitamin D. Normal weight adults (BMI 25 or lower) require at least 4000 IU supplemental vitamin D per day to maintain a serum level of 30 ng/ml. Elderly will require more. Most vitamin D researchers strive for 40-60 ng/ml, and follow the formula of 1000 IU per 25# body weight. https://www.medscape.com/viewarticle/819047. file:///C:/Users/Owner/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/9HFI89JI/chart-serum-level-intake-5-by-3-ngmla-both-charts-single.pdf. file:///C:/Users/Owner/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/9HFI89JI/Vitamin%20D%20Disease%20Prevention%20Chart%20with%20references.pdf. file:///C:/Users/Owner/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/9HFI89JI/A%20Statistical%20Error%20in%20the%20Estimation%20of%20the%20Recommended%20Dietary%20Allowance%20for%20Vitamin%20D.htm.

      Posted by Donna Bainbridge on 10/20/2017 2:24 PM

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