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Systematic Review of the Effect of Exercise in Community-Dwelling High-Risk Fallers Birring, Jason; Chan, Catherine; Mar, Tia; Sun, Rosy; Vishniakoff, Larissa; Liu-Ambrose, Teresa 2009

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SYSTEMATIC REVIEW OF THE EFFECT OF EXERCISE IN COMMUNITY-DWELLING HIGH-RISK FALLERSAuthors: Jason Birring, Catherine Chan, Tia Mar, Rosy Sun, Larissa VishniakoffSupervisor:  Dr. Teresa Liu-AmbroseOutlineBackground and RationaleMethodsResultsDiscussionConclusionImplicationsBackground and RationaleEpidemiology of FallsFalls are one of the leading cause of death among seniors11 in 3 people (65yo+) fall once per year2,3,450% will fall againDeath rate due to falls is higher in 	women5High-risk fallers have an increased 	sedentary lifestyleDecrease in strength & balanceFall ImplicationsIncrease morbidityMedical, psychological and social sequelae7Decreased self efficacy and independence6Increased mortality5Health care costs Canadians 2.8 billion dollars per year8Fall Prevention StrategiesPhysical activity8Strength and balanceReceiving relevant medical care2Managing and monitoring medications2Environmental modifications2Grab bars, railing, non-slip surfacesBehavioural modifications2Avoid high risk situations Current literature suggests exercise prevents falls in the geriatric population9,10,11Rationale for Systematic ReviewHigh-risk fallers are at increase risk of injurious falls leading to mortality and morbidityStatement of Purpose:Although there is a large body of research on falls, current literature does not provide concrete protocols for high-risk fallersResearch QuestionIn community-dwelling high-risk fallers, what is the effect of exercise on falls?MethodsOperational DefinitionsFallAn event that results in a person coming to rest unintentionally on the ground or lower level, not as the result of a major intrinsic event, such as stroke, or overwhelming hazard12High-Risk FallerRecurrent faller with a history of 2 or more non-syncope falls within a year13, orRecruited from emergency room due to non-syncope fallSearch StrategyElectronic Databases and Grey Literature: EMBASE, MEDLINE, CINAHL, PEDro, PubMed, cIRcle, google scholarReference tracking of selected articlesSearch terms:Recurrent fallers, history of fall, community dwelling, frail elder, exercise, sport, physical therapy, fall, fall risk, accidental falls, emergency, injurious, 	fracture, medical, fall preventionStudy CriteriaInclusion CriteriaPopulation:Men and women 65+ years oldHealthy participantsHistory of ≥2 non-syncope falls in last 12 months or recruited from emergency room due to non-syncope fallsNot residing in nursing homesIntervention:Includes an exercise componentIncludes pre and post dataOutcome:FallsExclusion CriteriaCognitive deficits (MMSE ≤24)Medical conditions increasing fall risk (cerebrovascular accident, Parkinsons disease, cardiac problems, transient ischemic attack)Evaluation of Methodological QualityPEDro Scale (0-10) 146+: High methodological quality4-5: Moderate methodological quality0-3: Low methodological qualityData Extraction and AnalysisData Extraction FormParticipants Inclusion/exclusion criteriaTraining parametersOutcome measuresResultsStatistical analysisData AnalysisQualitative synthesis of resultsDrop outsAdverse effectsStudy quality toolsStudy conclusionStudy limitationsResultsEligible Studies: 3657Title and Abstract Screening: 154Full Text Screening: 7 Search Strategy ResultsMethodological Quality of StudiesStudyPEDro ScaleSpice et al., 2008186Elley et al., 2008177Beyer et al., 2007165Mahoney et al., 2007196Skelton et al., 2005206Davison et al., 200567Hauer et al., 2001216Study CharacteristicsSpice et al., 200818Sample SizeMean Age% FemaleIntervention (I)Control (C)Outcome MeasureResultsI #1=136I #2=210C=159I #1= 83 I #2= 81   C = 83 I #1 =74.3%I #2 =71.3%C =76.1%Intervention #1: Multi-factorial (nurse lead Ax, referral to PT and other professionals)Intervention #2: Multi-factorial (multi-disciplinary Ax by MD, RN, OT, PT)Usual carePrimary:Proportion of fallersSecondary:Mortality,  functional mobility, fractures, move to institutional careI #1: I #2: No effect on falls Positive Effect: Reduced the risk for future fall by 9% Elley et al., 200817Sample SizeMean Age% FemaleIntervention (I)Control (C)Outcome MeasureResultsI = 155C =157I=80.4 C=81 I = 68%C=70%Multi-factorial (Nurse lead Ax, referral to interventions including Otago strength and balance exercise)Usual care and two social visitsPrimary:Rate of fallsSecondary: Strength, functional mobility, falls efficacyNo effect on falls Beyer et al., 200716Sample SizeMean Age% FemaleIntervention (I)Control (C)Outcome MeasureResultsI = 32C = 33I = 78.6C =77.6 100 %Exercise (6 months: warm up/cool down, flexibility, resistance training, balance)No activities providedPrimary:L/E strength, measures of mobility & balanceSecondary:Number of fallsNo effect on falls Mahoney et al., 200719Sample SizeMean Age% FemaleIntervention (I)Control (C)Outcome MeasureResultsI = 174C=175I = 79.6 C = 80.3 I =78.7% C=78.3%    Multi-factorial (Nurse or PT lead falls Ax, referrals to other professionals and recommendations for a balance and walking exercise plan)Home safety Ax and advise to see doctor Primary:Rate of fallsSecondary: Hospitalization, nursing home admissionNo effect on falls Skelton et al., 200520Sample SizeMean Age% FemaleIntervention (I)Control (C)Outcome MeasureResultsI = 50C = 31I =72.7 C=73.2 100% Exercise (FaME classes, Otago exercises and home exercise program) Home exercises programPrimary:Rate of fallsSecondary:Mortality, move to residential care or hospitalPositive Effect: 31% fewer falls in the intervention groupDavison et al., 20056Sample SizeMean Age% FemaleIntervention (I)Control (C)Outcome MeasureResultsI = 159C =154 7772%Multi-factorial (Ax, gait re-training and functional training program)Conventional carePrimary:Rate of falls and proportion of fallersSecondary:Hospital admissions,mortality,fear of fallingPositive Effect: 36% reduction in falls in the intervention groupHauer et al., 200121Sample SizeMean Age% FemaleIntervention (I)Control (C)Outcome MeasureResultsI = 31C = 2682 100% Exercise (3 months: Ambulatory training, functional performance and strength)Motor placebo activitiesPrimary:Rate of fallSecondary:Strength, ambulation speed,fear of falling,emotional status Non-significant Positive:25% reduction in falls in intervention groupSummary of ResultsStudy Design All RCTsPredominately female population3 exclusively female population: Beyer, Hauer, SkeltonRecruitment Hospital: Beyer, Davison, HauerFamily physicians: Elley, SkeltonCommunity advertisement: Mahoney, SpiceFalls Outcomes Reporting of fallsProportion of fallers: Beyer, Hauer, SpiceRate of falls: Mahoney, Elley SkeltonNumber of falls and proportion of fallers: DavisonEffects on decreasing fallsNo effect: Beyer, Elley, Mahoney, Spice (Intervention #1)Non-significant positive effect: Hauer (25%)Significant positive effect: Davison (36%), Skelton (31%), Spice (Intervention #2 – 9%)All but one study offered a strength and balance componentFrequency ≤3x/wk: Beyer, Elley, Hauer, Mahoney≥4x/wk: Davison, SkeltonUnreported: SpiceIntensity>70% max 1RM: Beyer, HauerModerate intensity: ElleyUnreported: Davison, Mahoney, Skelton, SpiceTime<3 months: Hauer6-9 months: Beyer, Elley, Skelton12 months: Mahoney, SpiceUnreported: DavisonContent of Exercise InterventionType of InterventionMulti-factorial vs. Exercise-aloneMulti-factorial: Elley, Davison, Mahoney, SpiceExercise alone: Beyer, Hauer, SkeltonGroup exercise vs. Individual exercise programsGroup exercise: Beyer, HauerIndividual exercise: Elley, Davison, SpiceBoth: SkeltonRecommendation for group exercise: MahoneyInclusion of home exercise program Elley, Davison, SkeltonAdherence to exercise  Good adherence: Beyer, Hauer, Skelton, SpicePoor adherence: ElleyNot reported: Davison(>75% participation to training program)DiscussionDiscussionLack of studies to conclude on the effects of exercise in high-risk fallersDue to heterogeneity of study design and implementation of articles reviewedTypes of InterventionsModerate support to recommend an individualized home-based exercise programMulti-factorial vs. Exercise-aloneLimited evidence on effectiveness of multi-factorial when compared to exercise-aloneChallenges to multi-factorial delivery: barriers to accessibility to multiple health care practitioners, confusion to priority of interventionsContent of Exercise InterventionProgram delivery has a greater influence on fall outcome than program contentSupervised exercise intervention is more effective than specific exercise recommendations2,20High frequency programs showed a greater decrease in fall outcomes2,20Program duration had no effect on fallsAdherence to exercisePrevious literature suggests group exercise program increases adherenceHowever,  this review cannot confirm these findingsContinual supervision and progression of exercise are required to maintain good adherenceAssociation between increase exercise adherence to decrease fall incidenceConclusionMain FindingsThe effect of exercise in high-risk fallers remains unclearThis systematic review suggests that interventions should include: A strength and balance componentGreater training frequencyAn individualised home exercise programGood adherence to supervised exercise programImplicationsRecommendationsRecommendations for CliniciansSupervised, moderate to high frequency of delivery of exercise program in a group-based or individualized setting can prevent fallsMulti-factorial or exercise-alone interventions result in equivalent outcomesChallenges in accessibility and motivational barriers may limit adherence to exerciseRecommendations for Future Research Standardizing reports of falls and outcome measuresVariability of measures used in falls research limit ability to perform statistical analysisArticles should be powered to show the effect of exercise at reducing injurious falls3Evaluate effectiveness of short-term vs. long-term exercise intervention Recommendations for Future Research Evaluate the relationship between exercise adherence and barriers to exerciseHigh-risk fallers have even greater barriersClinical trials need to evaluate the effects of exercise in high-risk community-dwelling fallersLimitationsHeterogeneity of study design and falls outcome measuresA meta-analysis could not be conductedOnly seven available RCTsParticipants may or may not have received exercise as an intervention within the multi-factorial studiesReferences1. Veterans Affairs Canada. 2002 May [cited 2009 Jun 10]: [2 screens]. Available from: ULR: http:/?www.acc-vac.gc.ca/clients/sub.cfm?source=health?fallsp2. Moreland J, Richardson J, Chan DH, O'Neill J, Bellissimo A, Grum RM, et al. Evidence-based guidelines for the secondary prevention of falls in older adults. Gerontology 2003 Mar-Apr;49(2):93-116.3. Tinetti ME. Multifactorial fall-prevention strategies: Time to retreat or advance. J.Am.Geriatr.Soc. 2008 August;56(8):1563-1565.4.  Loughlin JL, Robitaille Y, Boivin J, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am.J.Epidemiol. 1993 02;137(3):342-354. 5. Scott V, Pearce M, Pengelly C. Public health agency of Canada: Technical report: Deaths due to falls among Canadians age 65 and over an analysis of data from the Canadian Vital Statistics as presented in: Report on Seniors’ falls in Canada (section 2.4)6. Davison J, Bond J, Dawson P, Steen IN, Kenny RA. Patients with recurrent falls attending Accident & Emergency benefit from multifactorial intervention--a randomised controlled trial. Age Ageing 2005 Mar;34(2):162-168.7. Campbell AJ, Borrie MJ, Spears GF, Jackson SL, Brown JS, Fitzgerald JL. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age Ageing 1990;19(2):136-141.8. Public Health Agency of Canada. You can prevent falls fact sheet No. 5. 2006 Feb [cited 2009 Jun 10]: [2 screens]. Available from: URL:  http://www.phac-aspc.gc.ca/seniors-aines/pubs/Falls_Prevention/fallsprevtn5_e.htm9. Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JC. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J.Am.Geriatr.Soc. 2008 Dec;56(12):2234-2243.10. Petridou ET, Manti EG, Ntinapogias AG, Negri E, Szczerbinska K. What Works Better for Community-Dwelling Older People at Risk to Fall? A Meta-Analysis of Multifactorial Versus Physical Exercise-Alone Interventions. J.Aging Health 2009:0898264309338298v1.11. Chang JT, Morton SC, Rubenstein LZ, Mojca WA, Maglione M, Suttorp MJ, et al. Interventions for the prevention of falls in older adults: Systematic review and meta-analysis of randomised clinical trials. British Medical Journal 2004 328:680–686.12. Lord SR. Aging and falls: causes and prevention. J.Musculoskelet.Interact. 2007 Oct-Dec;7(4):347. 13. Morris R, Harwood RH, Baker R, Sahota O, Armstrong S, Masud T. A comparison of different balance tests in the prediction of falls in older women with vertebral fractures: A cohort study. Age Ageing 2007 Jan;36(1):78-83.14. Physiotherapy Evidence Database (PEDro).  Sydney: PEDro; 1999 [updated 1999 Mar; cited 2008 Nov 12]. PEDro scale [4 screens]. Available from: URL: http://www.pedro.org.au/scale_item.html15. Sackett DL. Rules of evidence and clinical recommendations for the use of antithrombic agents. Chest. 1986;89 2s-3s.16. Beyer N, Simonsen L, Bulow J, Lorenzen T, Jensen DV, Larsen L, et al. Old women with a recent fall history show improved muscle strength and function sustained for six months after finishing training. Aging Clin.Exp.Res. 2007 Aug;19(4):300-309.17. Elley et al. Effectiveness of a Falls-and-Fracture Nurse Coordinator to Reduce Falls: A Randomized, Controlled Trial of At-Risk Older Adults (See editorial comments by Dr. Mary Tinetti on pp 15631565). Journal of the American Geriatrics Society 2008;56(8):1383.18. Spice CL, Morotti W, George S, Dent THS, Rose J, Harris S, et al. The Winchester falls project: a randomised controlled trial of secondary prevention of falls in older people. Age Ageing 2008 October 1.19. Mahoney JE, Shea TA, Przybelski R, Jaros L, Gangnon R, Cech S, et al. Kenosha County falls prevention study: a randomized, controlled trial of an intermediate-intensity, community-based multifactorial falls intervention. J.Am.Geriatr.Soc. 2007 Apr;55(4):489-498.20. Skelton D, Dinan S, Campbell M, Rutherford O. Tailored group exercise (Falls Management Exercise -- FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age Ageing 2005 Nov;34(6):636-639.21. Hauer K, Rost B, Rutschle K, Opitz H, Specht N, Bartsch P, et al. Exercise training for rehabilitation and secondary prevention of falls in geriatric patients with a history of injurious falls. J.Am.Geriatr.Soc. 2001 Jan;49(1):10-20.We would like to thank:Teresa Liu-AmbroseCharlotte BeckElizabeth DeanDarlene ReidSymposium guestsAcknowledgementsQuestions? “”1=7**Meds + med careBehavioural mod? Actual strategies... Know...= Minimize fear of fallingTransition to popup: why focus on exercise? Sub bullets are to be said verballyBefore click: say “unknown which is the most effective strategy…CLICK… however currently literature…”**Define non-syncope*Regular updates from Medline, Embase, Cinahl*Verbally report: two indep reviewers (TM, RS) evaluated the methodological quality of the studies included*- 2 columns or 2 slidesVerbally explain:3 indep extractors…Statistical analysis was not conducted due to heterogeneity of studies but…**Explain primary and secondary careNurse delivered care vs. multiple assessment?-highlight main difference between 1 and 2*Let class know, they may or may not have gotten the intervention (multiple arms)*Specify what kind of fallPrimary outcome =  fall2ndary outcome = mobility (generally)- Orient the class I=intervention, C= control*Verbally report: >75% participation in training program = good adherence3 studies exclusively female population (hauer, skelton, beyer)*Make text bigger-rate of falls = more valid measure- Falls are not indep events in terms of stat analysis – recurrent fallers*Verbally report:Under Freq: “session duration ranged from 20-60mins”“mod intensity”*Define good adherence = add onto pie chart*“true”*Pattern did not suggest one type of delivery was better… but only 3 studies… not enough patternHave one sentence under 2nd point”Decrease effectiveness of single intervention”Verbally explain:multi-factorial interventions can be up to 12months therefore limiting ability to compare to exercise-alone (Last point)Add petridou notes*Avoid “correlation”Verbally report:Content of exs intervention…. Consistent with current literature*Emphasize it’s qual assessment“although we cannot conclude that an increase in exercise adherence CAUSES a decrease in falls…a correlation can be made between the two”*Based on cochrane review: 4 RCTs supports otago, home based strength/balance in general populationClinicians should continue to prescribe exercise in efforts to prevent fallsFactors to consider:strength and balance component of exercisefrequency of exercise participant adherence to exercise-Verbally report:- multi-factorial and individual exs programs are both beneficial… + factors to consider**-Since current methodology varies with respect to exercise duration and study effectVerbally report:- Under last point: “Use of matched-block design rather than purely random sampling may prevent clinician bias (Elley)”*2ndary measure: Physical functioning and self-efficacy measures were not analyzed * SYSTEMATIC REVIEW OF THE EFFECT OF EXERCISE IN COMMUNITY-DWELLING HIGH-RISK FALLERS Authors: Jason Birring, Catherine Chan, Tia Mar, Rosy Sun, Larissa Vishniakoff Supervisor: Dr. Teresa Liu-Ambrose  Outline Background and Rationale  Methods  Results  Discussion  Conclusion  Implications   Background and Rationale  Epidemiology of Falls   Falls are one of the leading cause of death among seniors1    1 in 3 people (65yo+) fall once per year2,3,4 5 50% will fall again    Death rate due to falls is higher in women5    High-risk fallers have an increased sedentary lifestyle  Fall Implications   Increase morbidity t  o  Medical, psychological and social sequelae7 Decreased self efficacy and independence6    Increased mortality5    Health care costs s  8  Fall Prevention Strategies   Physical activity8 y  Strength and balance  Current literature suggests Receiving relevant medical care Managing and monitoring medications exercise prevents falls in Environmental themodifications geriatric Grab bars, railing, non-slip surfaces 9,10,11 population 2    n  2  2    d    Behavioural modifications2 f  Avoid high risk situations  Rationale for Systematic Review   High-risk fallers are at increase risk of injurious falls leading to mortality and morbidity    Statement of Purpose: p  Although there is a large body of research on falls, current literature does not provide concrete protocols for high-risk fallers  Research Question    In community-dwelling high-risk fallers, what is the effect of exercise on falls?  Methods  Operational Definitions   Fall  An  event that results in a person coming to rest unintentionally on the ground or lower level, not as the result of a major intrinsic event, such as stroke, or overwhelming hazard12    High-Risk Faller A  s  Recurrent faller with a history of 2 or more non-syncope falls within a year13, or Recruited from emergency room due to non-syncope fall  Search Strategy   Electronic Databases and Grey Literature: a  EMBASE, MEDLINE, CINAHL, PEDro, PubMed, cIRcle, google scholar    Reference tracking of selected articles    Search terms: A  Recurrent fallers, history of fall, community dwelling, frail elder, exercise, sport, physical therapy, fall, fall risk, accidental  Study Criteria Inclusion Criteria       Population: A  Men and women 65+ years old  +  Healthy participants  a  History of ≥2 non-syncope falls in last 12 months or recruited from emergency room due to non-syncope falls  s  Not residing in nursing homes  Intervention: A  Includes an exercise component  c  Includes pre and post data  Outcome: A  Falls  Exclusion Criteria   Cognitive deficits (MMSE ≤24)    Medical conditions increasing fall risk (cerebrovascular accident, Parkinsons disease, cardiac problems, transient ischemic attack)  Evaluation of Methodological Quality   PEDro Scale (0-10) 14 0  0  0  6+: High methodological quality 4-5: Moderate methodological quality 0-3: Low methodological quality  Data Extraction and Analysis   Data Extraction Form F F i e e e    Participants Inclusion/exclusion criteria Training parameters Outcome measures Results Statistical analysis  h h h o o  Drop outs Adverse effects Study quality tools Study conclusion Study limitations  Data Analysis A  Qualitative synthesis of results  Results  Search Strategy Results Eligible Studies: 3657  Title and Abstract Screening: 154  Full Text Screening: 7  Methodological Quality of Studies Study  PEDro Scale  Spice et al., 200818  6  Elley et al., 200817  7  Beyer et al., 200716  5  Mahoney et al., 200719  6  Skelton et al., 200520  6  Davison et al., 20056  7  Hauer et al., 200121  6  Study Characteristics Spice et al., 200818 Sample Size  Mean Age  % Female  Intervention (I)  I #1= #1 =136 83  I #1 =74.3%  I  I #2 =71.3%  Intervention #1: Usual Multi-factorial care (nurse lead Ax, referral to PT and other professionals)  I  I #2= #2 =210 81 C=159 C = 83  C =76.1%  Intervention #2: Multi-factorial (multidisciplinary Ax by MD, RN, OT, PT)  Control Outcome (C) Measure  Results  Primary:  I #1:  Proportion of fallers  No effect on falls  #2 Secondary I : : Positive Effect: Mortality, Reduce functional d the mobility, risk for fractures, future move to fall by institution 9% al care  Elley et al., 200817 Sample Size  Mean Age  % Female  I= 155 C =157  I=80. I = 4 68% C=81 C=70 %  Intervention (I)  Control (C)  Outcome Measure  Multifactorial (Nurse lead Ax, referral to interventions including Otago strength and balance exercise)  Usual care and two social visits  Primary: Rate of falls Secondar y: Strength, functional mobility, falls efficacy  Results  No effect on falls  Beyer et al., 200716 Sample Size  Mean Age  I = 32 I = 78.6 C= C 33 =77.6  % Intervention Female (I)  Control (C)  Outcome Measure  100 % Exercise (6 months: warm up/cool down, flexibility, resistance training, balance)  No activiti es provide d  Primary: L/E strength, measures of mobility & balance Secondar y: Number of falls  Results  No effect on falls  Mahoney et al., 200719 Sample Size  Mean Age  I = 174 I = 79.6 C=175 C = 80.3  % Female  Intervention (I)  Control (C)  Outcome Measure  I Multi-factorial Home =78.7% (Nurse or PT safety C=78.3 lead falls Ax, Ax and advise %    referrals to to see other professionals doctor  Primary:  and recommendat ions for a balance and walking exercise plan)  Results  Rate of falls No effect on falls Secondary: Hospitalizati on, nursing home admission  Skelton et al., 200520 Sample Size  Mean Age  % Femal e  Intervention (I)  I = 50 I 100% Exercise =72.7 C= (FaME 31 C=73. classes, 2 Otago exercises and home exercise program)  Control (C)  Outcome Measure  Home Primary: exercis Rate of es falls progra m Secondar y: Mortality, move to residentia l care or hospital  Results  Positive Effect: 31% fewer falls in the interventi on group  Davison et al., 20056 Sample Size  Mean Age  % Femal e  Intervention (I)  I = 159  77  72%  MultiConvention factorial (Ax, al care gait retraining and functional training program)  C =154  Control (C)  Outcome Measure Primary: Rate of falls and proportion of fallers Secondary : Hospital admission s, mortality,  Results  Positive Effect: 36% reduction in falls in the interventio n group  Hauer et al., 200121 Sample Size  Mean % Intervention Age Female (I)  I = 31  82  C = 26  100%  Control (C)  Exercise (3 Motor months: placebo Ambulatory activities training, functional performance and strength)  Outcome Measure  Results  Primary: Rate of fall Secondary: Strength, ambulation speed, fear of falling, emotional status  Nonsignificant Positive: 25% reduction in falls in interventi on group  Summary of Results   Study Design A  All RCTs  A  Predominately female population 3  exclusively female population: Beyer, Hauer,  Skelton m Recruitment  Hospital: Beyer, Davison, Hauer  Family  physicians: Elley, Skelton  Community advertisement: Mahoney, Spice    Falls Outcomes A  Reporting of falls  Proportion  of fallers: Beyer, Hauer, Spice  Rate of falls: Mahoney, Elley Skelton  Number of falls and proportion of fallers: Davison  Effects on decreasing falls  No  effect: Beyer, Elley, Mahoney,  Spice (Intervention #1)  Non-significant  positive effect:  Hauer (25%)  Significant  positive effect:  Davison (36%), Skelton (31%), Spice (Intervention #2 – 9%)    Content of Exercise Intervention All but one study offered a strength and balance component  u  Intensity  >70% max 1RM: Beyer, Hauer   t  Elley  Frequency  ≤3x/wk: Beyer, Elley,    ≥4x/wk: Davison, Skelton    Unreported: Spice  Unreported: Davison, Mahoney, Skelton, Spice  Hauer, Mahoney   Moderate intensity:  ,  Time  <3 months: Hauer  6-9 months: Beyer, Elley, Skelton   12 months: Mahoney,    Type of Intervention t  Multi-factorial vs. Exercise-alone  Multi-factorial: Elley, Davison, Mahoney, Spice  Exercise  e  alone: Beyer, Hauer, Skelton  Group exercise vs. Individual exercise programs  Group  exercise: Beyer, Hauer  Individual exercise: Elley, Davison, Spice  Both: Skelton  Recommendation for group exercise: Mahoney o  Inclusion of home exercise program   Elley, Davison, Skelton    Adherence to exercise r e e  Good adherence: Beyer, Hauer, Skelton, Spice Poor adherence: Elley Not reported: Davison  (>75% participation to training program)  Discussion  Discussion   Lack of studies to conclude on the effects of exercise in highrisk fallers x  Due to heterogeneity of study design and implementation of articles reviewed    Types of Interventions n  Moderate support to recommend an individualized home-based exercise program  o  Multi-factorial vs. Exercise-alone  Limited  evidence on effectiveness of multifactorial when compared to exercise-alone  Challenges to multi-factorial delivery: barriers to accessibility to multiple health care practitioners, confusion to priority of interventions    Content of Exercise Intervention i  Program delivery has a greater influence on fall outcome than program content  Supervised  exercise intervention is more effective than specific exercise recommendations2,20  p  High frequency programs showed a greater decrease in fall outcomes2,20 Program duration had no effect on falls    Adherence to exercise r  Previous literature suggests group exercise program increases adherence  However,  this review cannot confirm these  findings e  Continual supervision and progression of exercise are required to maintain good adherence  u  Association between increase exercise adherence to decrease fall incidence  Conclusion  Main Findings   The effect of exercise in high-risk fallers remains unclear    This systematic review suggests that interventions should include: o a  d  A strength and balance component Greater training frequency An individualised home exercise program Good adherence to supervised exercise program  Implications  Recommendations   Recommendations for Clinicians f  Supervised, moderate to high frequency of delivery of exercise program in a group-based or individualized setting can prevent falls  s  Multi-factorial or exercise-alone interventions result in equivalent outcomes  s  Challenges in accessibility and    Recommendations for Future Research f  Standardizing reports of falls and outcome measures  Variability of measures used in falls research limit ability to perform statistical analysis  y  Articles should be powered to show the effect of exercise at reducing injurious falls3    Recommendations for Future Research f  Evaluate the relationship between exercise adherence and barriers to exercise  High-risk  fallers have even greater  barriers s  Clinical trials need to evaluate the effects of exercise in high-risk  Limitations   Heterogeneity of study design and falls outcome measures a  A meta-analysis could not be conducted    Only seven available RCTs    Participants may or may not have received exercise as an intervention within the multi-factorial studies  References    1. Veterans Affairs Canada. 2002 May [cited 2009 Jun 10]: [2 screens]. Available from: ULR: http:/?www.accvac.gc.ca/clients/sub.cfm?source=health?fallsp    2. Moreland J, Richardson J, Chan DH, O'Neill J, Bellissimo A, Grum RM, et al. Evidence-based guidelines for the secondary prevention of falls in older adults. Gerontology 2003 Mar-Apr;49(2):93-116.    3. Tinetti ME. Multifactorial fall-prevention strategies: Time to retreat or advance. J.Am.Geriatr.Soc. 2008 August;56(8):1563-1565.    4. Loughlin JL, Robitaille Y, Boivin J, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am.J.Epidemiol. 1993 02;137(3):342-354.    5. Scott V, Pearce M, Pengelly C. Public health agency of Canada: Technical report: Deaths due to falls among Canadians age 65 and over an analysis of data from the Canadian Vital Statistics as presented in: Report on Seniors’ falls in Canada (section 2.4)    6. Davison J, Bond J, Dawson P, Steen IN, Kenny RA. Patients with recurrent falls attending Accident & Emergency benefit from multifactorial intervention--a randomised controlled trial. Age Ageing 2005 Mar;34(2):162-168.    7. Campbell AJ, Borrie MJ, Spears GF, Jackson SL, Brown JS, Fitzgerald JL. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age Ageing 1990;19(2):136-141.    8. Public Health Agency of Canada. You can prevent falls fact sheet No. 5. 2006 Feb [cited 2009 Jun 10]: [2 screens]. Available from: URL: http://www.phac-aspc.gc.ca/seniorsaines/pubs/Falls_Prevention/fallsprevtn5_e.htm    9. Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JC. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J.Am.Geriatr.Soc. 2008 Dec;56(12):2234-2243.    10. Petridou ET, Manti EG, Ntinapogias AG, Negri E, Szczerbinska K. What Works Better for CommunityDwelling Older People at Risk to Fall? 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Beyer N, Simonsen L, Bulow J, Lorenzen T, Jensen DV, Larsen L, et al. Old women with a recent fall history show improved muscle strength and function sustained for six months after finishing training. Aging Clin.Exp.Res. 2007 Aug;19(4):300-309.    17. Elley et al. Effectiveness of a Falls-and-Fracture Nurse Coordinator to Reduce Falls: A Randomized, Controlled Trial of At-Risk Older Adults (See editorial comments by Dr. Mary Tinetti on pp 15631565). Journal of the American Geriatrics Society 2008;56(8):1383.    18. Spice CL, Morotti W, George S, Dent THS, Rose J, Harris S, et al. The Winchester falls project: a randomised controlled trial of secondary prevention of falls in older people. Age Ageing 2008 October 1.    19. Mahoney JE, Shea TA, Przybelski R, Jaros L, Gangnon R, Cech S, et al. Kenosha County falls prevention study: a randomized, controlled trial of an intermediate-intensity, community-based multifactorial falls intervention. J.Am.Geriatr.Soc. 2007 Apr;55(4):489-498.    20. Skelton D, Dinan S, Campbell M, Rutherford O. Tailored group exercise (Falls Management Exercise -FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age Ageing 2005 Nov;34(6):636639.  Acknowledgements We would like to thank: Teresa Liu-Ambrose Charlotte Beck Elizabeth Dean Darlene Reid Symposium guests  Questions?  

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