Wednesday, February 27, 2019 Large-Scale Investigation: Falls-Prevention Exercise Interventions Work An extensive review of more than 100 randomized controlled trials (RCTs) strongly supports exercise interventions as a way to reduce both the risk of falls among adults 65 and older and the actual number of those who experience a fall. What's less clear are some of the nuances of that finding—such as the effectiveness of resistance training or walking programs, and the differences between interventions provided by "health professionals" versus "trained providers who were not health professionals." The recently published Cochrane systematic review (abstract only available for free) focused on 108 RCTs involving 23,407 community-dwelling adults in 25 countries. Participants were an average age of 76, and 77% were women. The majority of participants lived in the community, and RCTs that focused on participants with conditions that increased the risk of falls—Parkinson disease, stroke, multiple sclerosis, dementia, hip fracture, and severe visual impairment—were excluded. The Cochrane reviewers analyzed various categories of exercise interventions versus control, which consisted of either no change in usual activities or an intervention not anticipated to reduce falls, such as health education, social visits, "gentle" exercises, or sham exercises. The exercise interventions were categorized as balance and functional; resistance; flexibility training; "3D" exercise including Tai Chi and Qigong; "3D" dance-based exercise; walking programs; endurance; "other"; and exercise interventions that included more than 1 of the studied categories. Among the findings: Overall, exercise reduces the rate of falls by 23% compared with control—but this difference doesn't seem to apply to individuals 75 or older. In terms of risk, authors found that, overall, individuals who received an exercise intervention from a trained health care professional had a 31% lower risk of falls compared with controls, while participants who received the intervention from providers who weren’t trained health care professionals had an 18% lower risk compared with control. Interestingly the differences between the trained and not-trained provider rates weren't present when researchers looked at individual programs that combined 2 or more exercise interventions. Overall, risk reduction was about the same for exercise interventions that were provided individually (21% risk reduction) versus in a group setting (24% risk reduction). In terms of specific types of exercise, the interventions researchers defined as focusing primarily on gait, balance, coordination, or functional task training were found to reduce falls by 24%. Tai Chi/Qigong was estimated to reduce falls by 19%, and a combination of 2 or more interventions was estimated to reduce falls by 34%. Studies on resistance training, danced-based exercise, and walking programs alone versus control didn't yield strong enough evidence to support a definitive conclusion. While a combination of interventions produced an overall reduction of 34%, authors found that when the most common combination—balance/functional exercises and resistance training—was looked at separately, the reduction rate remained nearly the same (31%). Balance and functional exercise interventions reported the best results in terms of reducing the long-term risk of falls (18 months or more post-intervention), with a reported 18% reduction versus control. Overall, exercise interventions were found to reduce the risk of later fall-related fractures by 27% and lower the risk of falls that require medical attention by 39%. While they acknowledge that there wasn't enough evidence for reviewers to look at the differences in exercise modality or doses, authors note that "there may also be longer-term benefits of introducing fall prevention exercise habits in people in the general community." They point out that most of the studies reviewed focused on programs that lasted 12 weeks or more, with nearly a third lasting a year or more. "These findings highlight the importance of primary prevention," they write. Even with the definitive conclusion on the overall effectiveness of exercise in falls prevention, authors of the review believe more work should be done to tease out the impact of various exercise programs, though they advise that the studies will need to be "very large." They also recommend further research into fall prevention programs in emerging economies "where the burden of falls is increasing more rapidly than in high-income countries," and the need to investigate how best to integrate falls prevention interventions into routine care of individuals 65 and older. Even with those gaps in evidence, "there is high-certainty evidence that falls can be prevented by exercise programs," authors write. "Exercise reduces both the rate of falls…and the number of people experiencing falls." APTA provides extensive resources on falls prevention at its Balance and Falls webpage. Offerings include consumer-focused information, online courses, and links to other sources of information, including the CDC and the National Council on Aging. In addition, APTA's PTNow evidence-based practice resource offers 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. The association's scientific journal, PTJ (Physical Therapy) has published a clinical guidance statement from the APTA Academy of Geriatric Physical Therapy on management of falls in community-dwelling older adults. Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.