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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 2009-07

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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 y Decrease in strength & balance Fall Implications  Increase morbidity t Medical, psychological and social sequelae7 o Decreased self efficacy and independence6  Increased mortality5 Health care costs s Canadians 2.8 billion dollars per year8 Fall Prevention Strategies  Physical activity8 y Strength and balance  Receiving relevant medical care2 n Managing and monitoring medications2  Environmental modifications2 d Grab bars, railing, non-slip surfaces  Behavioural modifications2 f Avoid high risk situations Curre t literature suggests exercise prevents falls in the geri ric population9,10,11 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 Recurrent faller with a history of 2 or more non-syncope falls within a year13, or s 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 falls, emergency, injurious, fracture, medical, fall prevention 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 6+: High methodological quality 0 4-5: Moderate methodological quality 0 0-3: Low methodological quality Data Extraction and Analysis  Data Extraction Form F Participants F Inclusion/exclusion criteria i Training parameters e Outcome measures e Results e Statistical analysis  Data Analysis A Qualitative synthesis of results h Drop outs h Adverse effects h Study quality tools o Study conclusion o Study limitations Results Eligible Studies: 3657 Title and Abstract Screening: 154 Full Text Screening: 7 Search Strategy Results 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) Control (C) Outcome Measure Results I #1=136 I #2=210 C=159 I #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 care Primary: Proportion of fallers Secondary : Mortality, functional mobility, fractures, move to institution al care I #1: I #2: No effect on falls Positive Effect: Reduce d the risk for future fall by 9% Elley et al., 200817 Sample Size Mean Age % Female Intervention (I) Control (C) Outcome Measure Results I = 155 C =157 I=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 visits Primary: Rate of falls Secondar y: Strength, functional mobility, falls efficacy No effect on falls Beyer et al., 200716 Sample Size Mean Age % Female Intervention (I) Control (C) Outcome Measure Results I = 32 C = 33 I = 78.6 C =77.6 100 % 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 No effect on falls Mahoney et al., 200719 Sample Size Mean Age % Female Intervention (I) Control (C) Outcome Measure Results I = 174 C=175 I = 79.6 C = 80.3 I =78.7% C=78.3 %    Multi-factorial (Nurse or PT lead falls Ax, referrals to other professionals and recommendat ions for a balance and walking exercise plan) Home safety Ax and advise to see doctor Primary: Rate of falls Secondary: Hospitalizati on, nursing home admission No effect on falls Skelton et al., 200520 Sample Size Mean Age % Femal e Intervention (I) Control (C) Outcome Measure Results I = 50 C = 31 I =72.7 C=73. 2 100% Exercise (FaME classes, Otago exercises and home exercise program) Home exercis es progra m Primary: Rate of falls Secondar y: Mortality, move to residentia l care or hospital Positive Effect: 31% fewer falls in the interventi on group Davison et al., 20056 Sample Size Mean Age % Femal e Intervention (I) Control (C) Outcome Measure Results I = 159 C =154 77 72% Multi- factorial (Ax, gait re- training and functional training program) Convention al care Primary: Rate of falls and proportion of fallers Secondary : Hospital admission s, mortality, fear of falling Positive Effect: 36% reduction in falls in the interventio n group Hauer et al., 200121 Sample Size Mean Age % Female Intervention (I) Control (C) Outcome Measure Results I = 31 C = 26 82 100% Exercise (3 months: Ambulatory training, functional performance and strength) Motor placebo activities Primary: Rate of fall Secondary: Strength, ambulation speed, fear of falling, emotional status Non- significant 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 ì 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%) — All but one study offered a strength and balance component t Frequency  ≤3x/wk: Beyer, Elley, Hauer, Mahoney  ≥4x/wk: Davison, Skelton  Unreported: Spice u Intensity  >70% max 1RM: Beyer, Hauer  Moderate intensity: Elley  Unreported: Davison, Mahoney, Skelton, Spice , Time  <3 months: Hauer  6-9 months: Beyer, Elley, Skelton  12 months: Mahoney, Spice  Unreported: Davison  Content of Exercise Intervention  Type of Intervention t Multi-factorial vs. Exercise-alone Multi-factorial: Elley, Davison, Mahoney, Spice  Exercise alone: Beyer, Hauer, Skelton e 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 Good adherence: Beyer, Hauer, Skelton, Spice e Poor adherence: Elley e Not reported: Davison (>75% participation to training program) Discussion Discussion Lack of studies to conclude on the effects of exercise in high- risk 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 multi- factorial 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 strength and balance component a Greater training frequency  An individualised home exercise program d 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 motivational barriers may limit adherence to exercise  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 s Evaluate effectiveness of short-term vs. long-term exercise intervention 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 community-dwelling fallers 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.acc- vac.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/seniors- aines/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 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.html  15. 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-Ambrose Charlotte Beck Elizabeth Dean Darlene Reid Symposium guests Acknowledgements Questions?

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